[Myocarditis or subendocardial myocardial infarction: role of MRI illustrated by a case report]

A 50-year-old male patient treated with mesalazine for Crohn's disease was admitted in our unit for a chest pain, associated with nonspecific ST depression or ECG and troponin elevation. Coronarography showed minimal changes while SPECT imagery suggested a posterobasal subendocardial infarction, so that the diagnosis was unclear between ischemic disease and mesalazine-induced myocarditis. Eventually, MRI demonstrated clearly a subendocardial posterior infarction eliciting the diagnosis of mesalazine-induced myocarditis. This case report illustrates, in our opinion, that MRI is of invaluable interest in evaluating the characteristics of myocardium, and must be the cornerstone in the diagnosis of myocardial diseases.

Randomised Trial Comparing Three Different Schedules of Infusional 5FU and Raltitrexed Alone as First-Line Therapy in Metastatic Colorectal Cancer

LV5FU2 with high-dose leucovorin (LV), weekly infusional 5-fluorouracil (5FU) (AIO schedule) and raltitrexed have been demonstrated to be active agents in first-line treatment of colorectal cancer. We performed a 4-arm randomised trial to compare (1) a low-dose intravenous bolus of LV (20 mg/m2), followed by an intravenous bolus of 5FU (400 mg/m2), followed by a 22-hour continuous infusion of 5FU (600 mg/m2) on day 1 and day 2/2 weeks (ldLV5FU2 arm), (2) a weekly continuous infusion of high-dose 5FU (2.6 g/m2/week) for 6 weeks followed by a rest week (HD-FU arm) and (3) raltitrexed (Tomudex arm; 3 mg/m2/3 weeks) to standard LV5FU2. From 1997 to 2001, 294 patients were included. The 4 arms were well balanced for sex ratio, age, WHO performance status, the primary tumour site and prior adjuvant chemotherapy. Treatment was stopped due to low accrual. Two toxicity-related deaths were observed in the Tomudex arm. The treatments gave rise to different rates of grade 3-4 neutropenia (3, 4, 11 and 14% of the patients in the LV5FU2, ldLV5FU2, HD-FU and Tomudex arms, respectively, p = 0.028), leucopenia and vomiting. At least one episode of grade 3-4 toxicity was observed in 27, 25, 38 and 47% of the patients in the LV5FU2, ldLV5FU2, HD-FU and Tomudex arms, respectively (p = 0.016). An objective response was observed in 28, 21, 22 and 10% of the patients in the LV5FU2, ldLV5FU2, HD-FU and Tomudex arms, respectively (p = 0.04). Progression-free survival (PFS) of the patients in the Tomudex arm was statistically lower compared to that of patients treated with LV5FU2 or ldLV5FU2 (combined group; p = 0.013, log rank test). In conclusion, Tomudex is more toxic and yields shorter PFS than infusional 5FU. Despite the early closure of the study and the lack of power of the comparison, it seems that ldLV5FU2 could be considered as an active, easier and less expensive option for the treatment of metastatic colorectal cancer compared to classic LV5FU2 or weekly HD-FU.

[Endoscopic treatment of Zenker's diverticulum using CO2 laser. 17 cases]

OBJECTIVES

Various treatment regimens have been used for the management of Zenker's diverticulum. These include surgery (transcervical diverticulectomy, myotomy) and endoscopic treatment with rigid instruments or flexible endoscope. The aim of this study is to report the results of the treatment of Zenker's diverticulum with rigid endoscope applied CO2 laser and to compare them with other types of treatment.

PATIENTS AND METHODS

Between May 1991 and November 1996, 17 patients (8 males, 9 females) with symptomatic Zenker's diverticulum underwent endoscopic treatment under short general anesthesia applied CO2 laser. The mean age of the patients was 73.2 years (range: 54 to 97 yrs). All patients had significant symptoms such as dysphagia (15 patients out of 17). All patients were clinically evaluated after the procedure.

RESULTS

The endoscopic incision was performed in one session per patient. Symptoms and dysphagia disappeared in all patients except one (dysphagia). Two complications (one cervical emphysema, one fistula) were managed clinically. Mortality was 0%. Mean follow-up was 17 months. There was no recurrence of dysphagia, all patients remained asymptomatic.

CONCLUSIONS

Rigid endoscopic treatment of symptomatic Zenker's diverticulum applied with laser CO2 is an efficient and safe method. It should be considered as an alternative therapy for Zenker's diverticulum, especially for patients at a high surgical risk.

[Acute cholecystitis in periarteritis nodosa. 8 cases]

OBJECTIVES

Analyze clinical manifestations and laboratory findings in patients with periarteritis nodosa who developed acute cholecystitis in order to determine their value for prognosis and management.

PATIENTS AND METHODS

We report 8 cases of acute cholecystitis which revealed or occurred as a complication of periarteritis nodosa. These were 4 men and 4 women, mean age 50 years. Periarteritis nodosa was diagnosed on the basis of histological evidence and/or clinical expression. Complimentary explorations included: sonography of the biliary tree, cholecystogram or cholangiogram in addition to diagnostic work-up for periarteritis nodosa.

RESULTS

The clinical or sonographic presentation was similar to common cases of cholecystitis. However, no stone were observed in 2/8 cases. Histologically, the gall bladder showed characteristic vascular lesions suggestive of periarteritis nodosa in 7 out of 8 cases (no operation in 1 case). Cholecystitis was the inaugural sign in 2 cases. Surgery was performed for lithiasic forms. Medical management with methylprednisolone i.v. was used successfully in the alithiasic forms. In the 2 cases with inaugural solitary acute cholecystitis. lithiasis was found in the surgical specimen in 1 case; the pathology examination gave the etiological diagnosis. There was no lithiasis in one case with inaugural cholecystitis.

CONCLUSIONS

The development of acute cholecystitis in patients with periarteritis nodosa is uncommon but should be treated surgically in case of lithiasis or when the cholecystitis is the inaugural sign. Unlike digestive tract involvement, periarteritis nodosa does not aggravate the clinical course. Alithiasic forms may be treated medically with corticosteroids. In our opinion, therapeutic abstention, sometimes proposed in patients with necrotizing angiitis of the gall bladder, is not always indicated as some patients can benefit from medical treatment of the underlying periarteritis nodosa.

[Hepatitis caused by clometacin (Dupéran). Retrospective study of 30 cases. A model of autoimmune drug-induced hepatitis?]

Thirty cases of clometacin-induced hepatitis were retrospectively collected over a nine-year period in hepatogastroenterological units of non university, public hospitals. There was a strong female predominance (90 percent). Clometacin (Dupéran) was taken because of arthritis in 8 out of 10 cases. Administration was continuous in 85 percent of cases and median duration was 445 days. median dose was 450 mg per day. Jaundice, fatigue, and weight loss were the most frequent symptoms, but edema, ascites and palmar erythema were not uncommon. Thrombopenia (38 percent) was the most frequent hematologic abnormality. Renal failure, always with benign course, was present in 1/4 of cases. Biochemical disorders indicated hepatocellular and cholestatic hepatitis in 3/4 and 1/4 of cases respectively. Hypoprothrombinemia below 50 percent was noted in 1 out of 6 cases, and was associated with death in half cases. Gamma-globulins were increased in 80 percent of cases, with a predominant increase of IgG. Antinuclear or anti-smooth muscle antibodies were present in 60 percent of cases, whereas antimitochondrial and antimicrosomes were absent. Histopathological examination of the liver biopsy specimens obtained in 25 patients showed acute hepatitis in 8 and chronic active hepatitis with fibrosis in 17--including 6 patients with cirrhosis; there were no epidemiological, clinical (except ascites), or biochemical differences between these two groups. Four of the 7 patients tested had HLA B8 antigens; they all had chronic active hepatitis, with autoantibodies in 3 cases. Median duration of hospitalization was 21 days. Hepatitis was directly responsible for death in 3 patients; biochemical sequelae (hypergammaglobulinemia or anicteric cholestasis) were present in 8 patients, 2 of whom most likely had cirrhosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Horton's disease: retrospective study of 33 cases and review of the literature]

Temporal arteritis is still often overlooked in 1982 as shown by the diagnostic delay reported in a retrospective review of 33 patients and in the series previously published in the medical literature. Clinical features to be especially kept in mind are the occasional nature of temporal signs, the pathognomonic value of jaw claudication and the existence of signs which may constitute a premonitory syndrome of blindness. The frequent rise in alkaline phosphatase levels is often misleading. In patients over 65 with an unexplained inflammatory syndrome, biopsy of both temporal arteries should be promptly performed, prior to the unpleasant and costly investigations designed to detect an occult carcinoma. Corticosteroids are still the best treatment of giant cell arteritis but the optimal initial dosage remains unknown as no data from randomized trials are available. Symptomatic relapses have been reported up to 10 years (5 years for ocular symptoms) after onset of the disease. Because of this protracted course, which makes adequate follow-up difficult to ensure, recovery rates from different series are at variance. The main side-effects of maintenance corticosteroid therapy in these elderly patients are osteoporosis, which warrants systematic countermeasures, and probably an increased rate of atheromatosis.

[Aortic stenosis associated with vascular malformations of the digestive tract. 2 cases (author's transl)]

Two patients with aortic stenosis had recurrent digestive haemorrhages. Fiberoscopy showed the presence of angiodysplasia of the stomach in one patient and of the colon in the other. This association had been reported in subjects older than 60. It does not seem to be fortuitous. The authors discuss the theoretical and practical implications, including the need for full radiological and endoscopic exploration of patients with recurrent digestive haemorrhages, particularly when associated with aortic stenosis.

[Distal mesenteric arteritis: a rare complication of D. methylsergide treatment (author's transl)]

A patient developed typical abdominal angina due to mesenteric arteritis secondary to D. methylsergide (Desernil) treatment. Multiple regular distal stenoses were revealed by arteriography, but these had completely disappeared 5 months after discontinuing treatment. Histology demonstrated fibrosis of the three tunicae with hyperelastosis. Six analogous cases due to D. methylsergide or ergotamine tartrate have been reported in the published literature, rapid regression occurring in all of them after interruption of treatment.

[Radiological, fibroscopical, histological and secretory gastric aspects in hemodialyzed patients (author's transl)]

Seventeen chronic hemodialyzed patients underwent a baryum meal, a fibroscopy with biopsic studies and an evaluation of gastric acid secretion. No duodenal ulcer was found. The gastric and duodenal folds are the most common anomaly. It has been not possible to correlate these folds to a precise histological entity. None of these patients exhibited an hypersecretory state, on the other hand 3 of them were hyposecreting. A statistical relationship between BAO on the one hand and PTH, CT and Ca on the other hand was found.

[Relationship between gastric acid secretion and plasma calcium, parathormone and calcitonin levels in patients with chronic renal failure on haemodialysis (author's transl)]

In twelve patients on chronic haemodialysis, a relationship was established between gastric acid secretion on the one hand, and certain parameters of calcium metabolism on the other hand: in a multifactorial statistical analysis, plasma calcium before dialysis (p less than 0,05), plasma parathormone levels before dialysis (p less than 0,05) and plasma calcitonin before dialysis (p less than 0,05) were variable explicatives of basal gastric acid secretion according to a direct relationship, whilst plasma calcium (p less than 0,05) was the only explicative variable of maximal gastric acid secretion after pentagastrin, with an inverse relationship. These preliminary results suggest that gastric acid secretion in the haemodialysis patient must be interpreted in the light of the state of calcium metabolism. Thus hypocalcaemia may be accompanied by decreased basal acid secretion and by contrast by an increased maximal acid secretion. These results require confirmation in a larger number of patients.

[Malignant non-secreting cortico-adrenalomas. Four cases (author's transl)]

In three of these four cases of malignant tumour of the adrenal cortex, a prolonged fever and a major inflammatory syndrome were the presenting features. The precise diagnosis was made before surgery only once. In two cases, it was a surgical discovery (one patient operated upon with a false diagnosis and another with no precise diagnosis). In the last case, the malignant tumour of the cortex was discovered at autopsy. The chief characteristics of these tumours are reviewed: rare ; presenting with chest pain, a mass in the hypochondrium, metastases, or general symptoms, possibly high and prolonged fever. The prognosis is gloomy, the majority of patients dying the six months which follow the operation.

[Prescribing tiapridal for headache and other painful conditions]

Tiapridal a new molecule of the benzamide family, raises the pain-threshold level in the mesolimbic system. It has been shown to be effective in 66% of cases of headaches and pain resistant to therapy, and 75% of patients with nausea and vomiting associated with headaches. The average dosage is between 150 and 300 mg or day (1/2 to 1 tablet, 3 times a day). The product is extremely well-tolerated. Somnolence, the most frequent side-effect was noted in 17% of cases. Because of its excellent tolerance it can be prescribed in debilitated patients, alcoholics, and the elderly.

[Intestinal hemorrhage due to blind loops. 3 cases and review of the literature]

The authors report 3 cases of intestinal bleeding either micro- or macroscopic induced by ulcers in blind loops. The blind loops developed in all 3 cases on side-to-side ileocolic anastomoses. In one of the patients, the ulcers were demonstrated by colonoscopy. The 3 cases reported are quite comparable to the 18 cases found in the world literature. These hemorrhages may become severe by their abundance or repetition, but a cure is easily obtained by resection of the intestinal blind loops and restoration of the continuity by end-to-end anastomosis.

[Malignant lymphopathy in a patient suffering from acute disseminated lupus erythematosus (author's transl)]

The authors report a case of acute disseminated lupus erythematosus in a 55 years old patient, receiving small doses of corticosteroids, progressing over three years. During an acute exacerbation of the disease, the development of a cervical adenopathy led to a biopsy. Histological examination revealed a lymphocytic type malignant proliferation (centro-follicular lymphoma). This case is compared with findings reported in the literature and leads to a discussion of the relationship between ADLE and malignant disorders due to a disturbance of immune control mechanisms and the possible role of immune-depressant therapy in their onset.

[Coxarthrosis due to contusion]

Can a contusion cause coxarthrosis in the absence of both fracture and dislocation? Yes. To demonstrate this the authors report 6 cases that fulfil the following conditions: (1) Simple but violent contusion affecting the greater trochanter or the knee (dashboard accident) or a forced movement, such as in doing the splits; (2) immediate or slightly delayed pain, generally of short duration (a few weeks); (3) absence of coxarthrogenic malformations and absence of pre-existing signs of a pathological hip condition; (4) progressive coxarthrosis on the side of the contusion; (5) chronological relation between the development of the coxarthrosis images and the date of the contusion; (6) subjects less than 35 years of age, in order to eliminate cases with latent primary pre-coxarthrosis. The average age of the six patients at the start of the coxarthrosis was 24.7 years (range: 13 to 33 years); there were four men and two women. In five of the six cases a violent contusion in the trochanter region was involved as a result of a fall on a hard surface or a traffic accident. In one case a forced movement on landing from a jump was involved. Evolution in three periods is usual: the hip is painful either immediately or after a few weeks (particularly on rising after a period in bed for multiple injuries). This post-traumatic pain lasts from ten days to one month, rarely longer. It is followed by a period free of pain that may last from five months to ten years (average: five years). Subsequently there is pain every day and the onset of the limp associated with coxarthrosis. Radiographically the reduction of the joint space and/or the osteophytosis appears after three months to two years (average: one year). However, there may not be any pain associated with these lesions for a long time. The authors propose that the first five conditions enumerated above represent the essential medico-legal conditions of coxarthrosis by contusion. The restriction as regards age (No 6) was introduced only to show clearly the existence of post-contusive coxarthrosis. However, even if one or more of the medico-legal conditions are not fulfilled the imputability may still be valid. Some such cases are discussed.