[Non-tuberculous systemic granulomatosis mimicking sarcoidosis but related to a specific etiology. Study of 67 cases]

PURPOSE

Systemic granulomatosis (SG) are frequently encountered in internal medicine. Despite a large list of aetiologies, the investigations remain often negative leading to the diagnosis of atypical sarcoidosis. The spectrum of the causes, as well as evolution of these SG is not clearly delineated in the literature.

METHOD

We analyzed the case reports of all but tuberculous GS submitted at the National Meetings of the National French Society of Internal Medicine from 1990 to 2006.

RESULTS

Sixty-seven cases were included in the study. The average age at the beginning of the symptoms was 47.8 years and 28.4% of the patients were female. The median diagnostic delay was one year. General symptoms were present in 73.1% of the cases. The involved organs were the liver (46.3%), lungs (25.4%), lymph nodes (22.4%), digestive tract (16.4%), skin (16.4%), spleen (14.9%). The granuloma were detected mainly in the liver (38.8%), lymph nodes (17.9%), bone marrow (16.4%) and lungs (11.9%). Elevated erythrocyte sedimentation rate or increased C reactive protein serum levels were noted in 65.6% of the patients. Before diagnosis, 19.4% of the patients received a corticotherapy. The most common diagnoses were infections (65.6%) followed by drugs (19.5%), "toxic substances" or various foreign bodies (5.9%), neoplasias (5.9%) and immune deficiencies (3%). The evolution was favourable in 80% of the cases but 8.3% of the patients died. The disease course of the patients having received a corticotherapy prior to the diagnosis was more unfavourable with a death rate of 45%.

CONCLUSION

In atypical sarcoidosis (fever, advanced age, increased acute phase reactants...) a specific aetiology and especially an infectious disease should be ruled out before considering the diagnosis of sarcoidosis. Corticotherapy is a factor of poor prognosis.

Tuberculomes et méningoradiculite tuberculeuse d’évolution paradoxale sous traitement

INTRODUCTION

Neuromeningeal tuberculosis of deleterious, paradoxical, progression despite appropriate antibiotic therapy is rare.

OBSERVATION

An immunocompetent woman exhibited an immediately disseminated form of tuberculosis with progressive neurological involvement associating expanding intracranial tuberculomas and meningeal-radiculitis despite adapted anti-tuberculosis quadritherapy.

DISCUSSION

During anti-tuberculosis therapy clinical worsening is rare, particularly when 2 different manifestations are associated and the worsening occurs in an immunocompetent patient. This possibility should be systematically evoked in such cases. The explanation of this phenomenon is still unclear.

Pandysautonomie paranéoplasique avec anticorps anti-Hu : révélation d’un adénocarcinome bronchique par le PET scan

A 74-year-old man developed pandysautonomia with severe orthostatic hypotension. Search for a paraneoplastic etiology was confirmed with the positivity of anti-Hu antibodies. [18] Fluorodeoxyglucose positron emission tomography (PET) enabled recognition of a lung adenocarcinoma. We emphasize the usefulness of PET scans for early diagnosis of cancer.

Méningites puriformes aseptiques chez l’adulte

OBJECTIVE

The objective of this study was to analyze the characteristics of a series of acute aseptic meningitis (AAM) (defined by sterile cerebrospinal fluid (CSF) with more than 10 leucocytes per mm3 and a neutrophilic polynuclear-rich formula). We analysed the initial management, the reasons for antibiotic and/or antiviral treatment, the aetiologies, the need for lumbar puncture and the progression...

METHOD

We retrospectively analyzed 32 cases of AAM (out of a total of 130 cases of meningitis) from two departments of internal medicine in Lyon, diagnosed between January 1996 and January 2003. Only the files fulfilling the AAM criteria were retained, selecting those with a minimum neutrophilic polynuclear level of 30% in the CSF.

RESULTS

The mean age was 32.6 years (range: 18-75) and predominantly male patients (59%). On admission, 87% of the patients exhibited fever, but only 9% remaining so for 72 hours. Viral syndrome before admission was noted in 59% of cases, with seasonal predilection (summer: 39%, winter: 35%). The motivation for lumbar puncture (LP) was meningeal syndrome (44%), headache (94%) and vomiting (47%). The average rate of neutrophils in the CSF on admission was 63% (range: 30-96). A control LP on Day 3 was performed 16 times (50%): mean PNN rate at 18% (range: 0-80), lymphocyte rate=68% (range: 20-95). Most of the patients (77.4%) had a C reactive protein (CRP) lower than 50 mg/l on admission (range: 5-320). A cerebral scan was performed 10 times (31%) and was abnormal 2 times (multiple cerebral abscesses, possible intracranial hypertension). An antibiotic (84%) and/or antiviral (34%) treatment was initiated. The evolution on Day 3 was favourable (87.5%): no fever, regression of the meningeal syndrome, with a mean duration of hospitalisation of 8.3 days (range: 1-60). Search for Herpes simplex virus and Enterovirus was made with PCR analysis in 20 cases (62.5%): no positivity for the herpes, but 9 for the Enterovirus. The systematic blood cultures were positive only once (staphylococcal infective endocarditis with cerebral abscesses). The diagnosis of bacterial meningitis was evoked 3 times (prior antibiotic treatment).

DISCUSSION

The frequency of Enterovirus AAM should encourage this type of investigation in order to withdraw the often initiated anti-infectious treatment rapidly, and hence avoid a second lumbar puncture.

[Acute renal failure during severe malaria: physiopathology and therapeutic management. Apropos of 2 cases]

Renal failure secondary to acute tubular necrosis is a common complication of severe Plasmodium falciparum malaria. The purpose of this report is to describe two cases of severe malaria featuring acute renal failure observed in young patients who had failed to comply with chemoprophylaxis. Occurrence of renal failure was delayed four to seven days in relation to the beginning of the malaria attack. Hemodialysis was required in one case. Both patients were successfully treated by quinine perfusion. The main pathophysiology mechanisms underlying acute tubular necrosis are obstruction of capillaries and post-capillary venules by infected red blood cells and activation of monocytes that release cytokines such as tumor necrosis factor. Other nonspecific mechanisms may come into play including hypovolemia, release of catecholamines and subsequent activation of the rennin-angiotensin system, complement activation, and rhabdomyolysis. Acute tubular necrosis is the main renal complication of Plasmodium falciparum malaria but latent forms of acute glomerulonephritis have also been documented. Prognosis is usually favorable depending mainly on early diagnosis and prompt treatment.

[Intestinal pneumatosis. Right colon cystic form with linear aspect on scan]

INTRODUCTION

Digestive pneumatosis corresponds to the presence of air in a wall of digestive tract. It is common to oppose primary cystic-type pneumatosis, involving the left colon, with linear-type pneumatosis that may affect the whole of the digestive tract.

OBSERVATION

In a 41 year-old man presenting with Sharp's syndrome, abdominal pain occurred revealing an isolated right colon pneumatosis. Although abdominal tomodensitometry showed a strictly linear pneumatosis, colposcopy revealed voluminous cysts.

CONCLUSION

With this case report, the limits of tomodensitometry in distinguishing linear from cystic forms are apparent. The importance of avoiding surgery is underlined. Our patient presented with a pneumo-peritonitis only requiring medical treatment since this disease generally regresses spontaneously.