Investigation of fluoroquinolone-induced myalgia using (31)P magnetic resonance spectroscopy and in vitro contracture tests

OBJECTIVE

To investigate muscle function in patients with severe myalgia resulting from fluoroquinolone (FQ) treatment. We used histology, in vitro contracture tests (IVCTs), and (31)P magnetic resonance spectroscopy ((31)P MRS) to explore muscle contraction and metabolism.

METHODS

We studied 3 patients with myalgia, hyperalgia tendinopathy, and arthralgia following FQ treatment and 3 normal subjects after taking FQs. Results were compared with those of a control group of 9 subjects free of any muscle disease and not taking FQs. Muscle biopsies were performed on the left biceps, and IVCTs were performed in accordance with the protocol recommended by the European Malignant Hyperthermia Group. (31)P MR spectra of forearm flexor muscles were recorded at 4.7T throughout a rest-exercise-recovery protocol.

RESULTS

(31)P MRS showed a significant reduction of pH changes measured at the end of exercise and a faster rate of proton efflux measured during recovery in all patients. IVCTs diagnosed 1 patient as being susceptible to malignant hyperthermia. No specific histologic anomalies were observed in muscle biopsy samples, which showed normal mitochondria.

CONCLUSION

The adverse effects recorded in the 3 patients are related to a preexisting muscular anomaly revealed by FQ treatment.

[Lead poisoning in adults. Experience of the Poison Control Center of Marseille from 1993 to 2000]

OBJECTIVE

Report the experience of the Marseille's anti-poison center with lead poisoning adults.

PATIENTS AND METHODS

Between 1993 and 2000, 45 adults patients consulted the poison Centre of Marseille for a history of lead exposure (9 women, 36 men, average age 44 YO, between 22 an 76 YO). The lead sources were mostly occupational (welding, heavy metal industries...), but some were environmental (shooting as a hobby, hunting,...).

RESULTS

Ninety-one percent of the patients presented with a clinical feature of possible lead intoxication (asthenia, abdominal pain, anaemia, seizures,...). For 22 patients, calcitetracemate provocation test was negative. 6 patients with a positive test refused to be treated. 16 patients with a positive test were treated with chelation therapy (average lead blood level 566 micrograms/l--mini 320 micrograms/l, maxi 943 micrograms/l--and average lead urine elimination 3,011 micrograms/24 H--mini 789 micrograms/24 H, maxi 7,229 micrograms/24 H. 58 cures were done (1 to 12 cures for each patient). The average quantities of lead eliminated in the urine during the chelation therapy was 30,912 micrograms +/- 29,059 micrograms by case. For 12 patients who stopped the lead exposure after the diagnosis of lead poisoning, the chelaion therapy permitted to decrease the lead blood level of 69%. For 4 patients still exposed during the treatment, the lead blood level decrease of 7% only. For the 16 treated patiEnts, a clinical improvement was noted, and no adverse effects of chelation therapy was observed during the 58 cures.

Malignant hyperthermia susceptibility revealed by myalgia and rhabdomyolysis during fluoroquinolone treatment

Fluoroquinolones cause myalgia, but this complication is not clearly documented. We describe a patient who developed myalgia and rhabdomyolysis during fluoroquinolone treatment. The patient was a 33-year-old man treated with norfloxacin for common cystitis. He complained of general muscular fatigue, tendon disorders, and articular pain during treatment. When the antimicrobial agent was stopped, symptoms decreased, with persistence of slight myalgia for 10 days. Rhabdomyolysis was detected. Six months later, investigation by 31P magnetic resonance spectroscopy revealed an oxidative disorder and an abnormal abundance of phosphomonoesters. In vitro contracture tests led to a diagnosis of malignant hyperthermia susceptibility. Our case shows that for any subject presenting myalgia with rhabdomyolysis triggered by fluoroquinolone treatment, the presence of a latent myopathy should be investigated.

Cannabis arteritis revisited--ten new case reports

The purpose of this paper was to revisit the old concept of cannabis arteritis first described in the 1960s and report 10 new cases. Ten male patients, with a median age of 23.7 years developed subacute distal ischemia of lower or upper limbs, leading to necrosis in the toes and/or fingers and sometimes to distal limb gangrene. Two of the patients also presented with venous thrombosis and three patients were suffering from a recent Raynaud's phenomenon. Biological test results did not show evidence of the classical vascular risk factors for thrombosis. Arteriographic evaluation in all cases revealed distal abnormalities in the arteries of feet, legs, forearms, and hands resembling those of Buerger's disease. A collateral circulation sometimes with opacification of the vasa nervorum was noted. In some cases, arterial proximal atherosclerotic lesions and venous thrombosis were observed. All patients were moderate tobacco smokers and regular cannabis users. Despite treatment with ilomedine and heparin in all cases, five amputations were necessary in four patients. The vasoconstrictor effect of cannabis on the vascular system has been known for a long time. It has been shown that delta-8- and delta-9-tetrahydrocanabinols may induce peripheral vasoconstrictor activity. Cannabis arteritis resembles Buerger's disease, but patients were moderate tobacco smokers and regular cannabis users. These cases show that prolonged use of cannabis could be an additive risk factor for juvenile and young adult arteritis. Cannabis arteritis is a forgotten and severe occlusive vascular disease occurring in young adults. Search for cannabis use may be an important tool for a better knowledge of arteritis in young smokers.

[Methamidophos intoxication: immediate and late neurological toxicity; two case reports]

Méthamidophos is an organophosphorus insecticide which delayed neurotoxicity is more frequent than with other organophosphates. Authors present a case report concerning a collective poisoning after cutaneous contact: two farm labourers presented moderate cholinergic signs quickly followed by proximal neurological signs (retrobulbar ocular neuritis for one patient, thight paresthesias for the second one). These signs decreased meanwhile new neurological symptoms appeared: sensory and motor peripheral neuropathy in both patients, with a clinical aspect of OrganoPhosphorus Induced Delayed Neuropathy (OPIDN). This unusual chronology and the disappearence of all signs at the 18th month, lead the authors to diagnose a collective methamidophos poisoning in three phases: first, anticholinesterasic acute syndrome; second, an intermediate syndrome and third an OPIDN.

[Impact of delta-9-tetrahydrocannabinol and its metabolites on the immune system]

Many studies obvious impact of cannabinoids on the immune system. These studies follow the rapid advanced researches led in the immunology field. D9 Tetrahydrocannabinol and their metabolites decrease production of tumoral necrosis factor alpha. This decrease has for consequence a decrease of the apoptosis. Recent discovery of implication of cytokines in the phenomena of dependence, make the cannabis and their metabolites promoting agent induced dependence in association with drug abuse. The withdrawal of these products necessitates a intact immune system. D9 Tetrahydrocannabinnol and their metabolites inhibit production of IL-1 and gamma interferon. This inhibition has for consequence a decrease of 33% of the lymphocytes activity and an inhibition of 66% of the lymphocytes adenyl cyclase activity. The consumption of cannabis decreases immunological competence of macrophages, and alterate their essential role of trophicity of the nervous central system. Furthermore, inhibiting actions of cannabinoids on the cyclo-oxygenase, promote production of arachidonic acid degradation products. This compounds mimic the action of histamine, and inducing a raise of the vascular permeability and bronchospasm. These inolecules contributes at delayed reaction of anaphylaxia. However these actions of cannabinoids on the immune system promote their pull-back in cure of new pathology likes AIDS.

[Cannabis-induced arteritis vs. Léo Buerger disease. Nosologic discussion apropos of two new cases]

BACKGROUND

We observed two cases of juvenile endarteritis which might suggest a possible link between Winiwarter-Buerger disease and cannabis-induced endarteritis.

CASE REPORTS

Our two patients were young men aged 18 and 20 years. Both developed acute distal ischemia of the lower or upper limbs with arteriographic evidence suggestive of Winiwarter-Buerger disease. Both smoked regularly but not excessively and both used cannabis regularly. In one case, the therapeutic response to withdrawal of cannabis was good. In the second, use of cannabis continued and arterial disease persisted.

DISCUSSION

The cause of Winiwarter-Buerger disease remains elusive although smoking is undoubtedly involved in the pathogenic mechanism. Our two cases recall the cannabis-induced endarteritis described in the sixties in Kif smokers in North Africa. The main clinical and radiographical features in this condition are the same as in Winiwarter-Buerger disease.

CONCLUSION

Winiwarter-Buerger disease and cannabis-induced endarteritis are 2 very similar conditions. The probably rare finding of juvenile endarteritis mimicking thromboangeitis obliterans should, in our opinion, be considered as a secondary and possibly toxic effect of cannabis.

[Snake bite by European vipers. A multicenter study of tolerance to Viperfav, a new intravenous antivenom]

OBJECTIVES

To evaluate the tolerance and the effectiveness of i.v. Viperfav, a new antivenom containing F(ab')2 fragments of equine antibodies, for the treatment of European viper envenomed patients.

STUDY DESIGN

Open, multicentre field trial, associated with a cohort study.

PATIENTS

The study included 46 patients of either gender, nine aged less then 10 years, eight between 10 and 15 years, and 28 adults, who sustained a moderate or severe viper envenomation (Grade 2 or 3).

METHOD

At the inclusion, a single infusion of Viperfav was given. Depending on the clinical course, up to four additional infusions were to have been administered at 4-hour intervals. To evaluate tolerance, all symptoms were recorded. There were three effectiveness evaluation criterion (duration of hospitalisation, course of the severity grade, recovery (sequelae)) and one subjective criteria (value of the antivenom as ascertained by investigators).

RESULTS

In the 46 included patients, 79 infusions were administrated. Concerning tolerance, six mild symptoms were associated to the antivenom infusions. No severe reaction occurred. The mean duration of hospitalisation was 4 days 19 hours +/- 13 hours. A severity grade decrease by at least one point was observed in 35 patients, and all were discharged without sequelae. For the investigators the antivenom was inefficient in only two patients (grade 3 with tissue lesions).

CONCLUSIONS

In comparison with literature data (5 to 10% of severe reactions attributable to the antivenom), the tolerance of Viperfav can be considered as satisfactory. As all criteria were in favour of a positive benefit to risk ratio, the authors recommend the use of Viperfav i.v. for the grade 2 and 3 envenomations instead of the current less purified antivenom, which can only be administered by the intramuscular route.

[Acute renal insufficiency caused by Amanita proxima poisoning: experience of the Poison Center of Marseille]

In southern France, some Amanita species are usually eaten like Amanita ovoidea (Quélet, 1872) which is a common white mushroom. In same areas, a similar and less common fungus can be encountered: Amanita proxima (Dumee, 1916). The first published cases of Amanita proxima poisonings with acute renal failure have been reported in 1994 by a medical team from Montpellier. A second article was published in 1995 by physicians from Marseille. In order to evaluate the importance of the confusion between the 2 species, we looked after these mushroom poisonings collected by the Poison Centre of Marseille. We found 31 cases concerning 53 patients. We observed the first intoxication in 1968. Poisonings took place in the south of Provence. Ingestions are in 26 cases (83% of the 31 cases) due to the confusion with Amanita ovoidea. The average delay between the meal and the first signs was 13 hours and 12 minutes. All patients had gastro-intestinal symptoms, and for 14 of them, oliguria or anuria appeared in a few days after ingestion. 11 patients needed temporary dialysis, and for 10 of them, moderate hepatic cytolysis was observed. The severity of symptoms seems to be dose-dependent: we collected cases in the same family with no signs after just tasting the meal, digestive symptoms only when patients at more, and renal failure for the hungry people.

[Study of narcotics and buprenorphine prescriptions in the Provence-Alps-Côte d'Azur region]

Following the setting up by the Government of their project for the management of drug addicts, and under the guidance of the CEIP (Centre d'Evaluation et d'Information sur les Pharmacodépendances [Centre for Evaluation and Information on Drug Addiction]) in Marseille, a survey of prescriptions written on controlled-drug prescription pads was performed. The aims were threefold: to study the medicines prescribed, to follow up the legislation and to inform doctors and pharmacists. Copies of the prescriptions, dated between 1 January 1996 and 30 June 1996, which were sent by 81 per cent of the 216 pharmacies contacted in 15 towns in the Provence-Alpes-Côte d'Azur (PACA) region were studied. Various criteria, relating to writing of the prescriptions and distribution of the medicines to the patients, were coded and analysed. This survey showed that of 4 prescriptions, 3 were prescribed for maintenance and one for analgesic therapy. The patients receiving maintenance therapy were male in three-quarters of the cases, and were around 30 years old. Analgesics were prescribed in equal proportions for patients of both sexes, who were around 65 years old. Since it was put on the market, Subutex has been quickly prescribed.

[Severe potassium dichromate poisoning after accidental nasal introduction]

BACKGROUND

Nasal foreign body (NFB) is a common situation in pediatrics. Poisoning is a rare complication of NFB insertion. We report a case of acute potassium dichromate poisoning secondary to NFB insertion.

CASE REPORT

Six days after insertion of a NFB, progressive occurrence of diarrhea, vomiting, nasal obstruction, acute renal failure, pancreatitis, hepatitis and drowsiness justified hospitalization of a 3-year-old girl in the pediatric intensive care unit. Acute potassium dichromate poisoning was confirmed by high plasma chromium level and by the spectrophotometric analysis of the crystal. Recovery was satisfactory with supportive treatment. An official survey allowed to discover that the crystal was freely sold and that its toxicity was unknown by dealers, while no information was given to the customers.

CONCLUSION

Transmucosal absorption of toxics is an unusual severe potential hazard that should be evoked to allow a rapid management. After the discovery and withdrawal of a NFB, occurrence of systemic symptoms, even trivial, must make one suspect a poisoning. In this circumstance, analysis of the foreign body should be done, associated with toxicologic dosages. This case report illustrates that potassium dichromate poisoning is a severe medical condition and that its clinical presentation assume a large widespread of symptoms due to multiple organ involvement.

[Occlusion of the central retinal vein after vaccination against viral hepatitis B with recombinant vaccines. 4 cases]

OBJECTIVES

Hepatitis B vaccination has been proven to be effective and well-tolerated. Certain neurological, ocular or systemic complications have, however, been reported to be induced by the vaccine. Clinicians should be aware of exceptional ocular complications.

CLINICAL REPORT

Four patients under 50 years of age developed occlusion of the central vein of the retina after vaccination with recombinant hepatitis B vaccine. None of the classical causes of occlusion of the central vein of the retina could be evidenced.

DISCUSSION

Several pathophysiological hypotheses have been proposed to explain these ocular manifestations after vaccination: role of immunocomplexes, antigenic cross-reactions, role of immediate hypersensitivity, simulation of a pathogenic lymphocyte repertoire. None of these hypotheses is entirely satisfactory. It is important however to emphasize the need for a complete general evaluation, including an ophthalmological examination in the presence of unexplained ocular manifestations following hepatitis B vaccination.

[Mass ciguatera poisoning after eating barracuda in Mexico: prognostic and therapeutic implications]

Thirty patients were admitted to the Anti-Poison Center of Marseille, France, on the fifth day of ciguatera fish poisoning due to ingestion of the same barracuda in Mexico. The purpose of this prospective study conducted during management of this group was to identify prognostic factors and evaluate the efficacy of treatment using mannitol. Upon admission severity was individually scored based on clinical findings. Twenty-two patients exhibiting the highest severity scores were immediately treated by infusion of 250 ml of 20% mannitol within one hour. These patients presented low plasma cholinesterase levels. Treatment led to transient improvement mainly with regard to cramping and digestive manifestations. All patients who presented high severity scores upon admission reported persistent manifestations lasting between 1 and 7 months. In 6 of these patients symptoms recurred after ingestion of seafood and/or alcohol. The fact that the extent of clinical symptoms in terms of severity and duration was correlated with the amount of fish ingested confirms that ciguatera poisoning is dose-dependent in man. However cholinesterase levels were not correlated with the severity of clinical manifestations.

Central and peripheral neurotoxic effects of chronic methyl bromide intoxication

OBJECTIVE

To examine all methyl bromide poisonings reported to the Marseille Poison Centre and to describe more precisely the infrequent cases of chronic, nonacute exposure.

DESIGN

Retrospective observational cohort.

METHOD

Data retrieval from the French Poison Centres National Data Bank (ARIT) which contains all the cases of poisonings collected by the Marseille Poison Centre (Hot Line observations, Toxicovigilance, Toxicological intensive care unit). All methyl bromide poisonings 1973-1994 were examined to evaluate to frequency of the different circumstances.

RESULTS

Of the 89 methyl bromide intoxications studied, there were two cases of chronic exposure: two workers presented with neurological signs of cerebello-vestibular and pyramidal deficits, visual troubles and peripheral neuropathy of the lower limbs at the end of a season of exposure during which no acute incident involved. In one patient, the symptoms improved within five months; in the other, paresthesia were still present two years later and were associated with visual after-effects.

CONCLUSION

The incidence of chronic methyl bromide intoxication is low. The risk for chronic exposure or persistent toxic effects may be masked by the severity of the acute toxic effects. The development of peripheral neuropathy immediately after the central neurological signs was noted in our two subjects. A dying back axonopathy may explain this unique chronological evolution.

[Reactive airway dysfunction syndrome and bronchiolitis obliterans after exposure to acid vapors]

A 37-year-old male non-smoker developed rapidly severe respiratory disease after a 3-hour exposure to hydrobromic acid fumes. An upper airway syndrome ensued with anosmia and aphonia as well as non-specific bronchial hyperreactivity, obstructive bronchiolitis (which led to a persistent respiratory volume of about 20% of the normal level with exercise-induced dyspnea) and obstructive bronchiolitis. Lung transplantation is currently being considered. When inhaled at irritant concentrations, certain toxic gases, such as chlorine, can lead to reflex apnea via laryngeal nerve reaction, limiting gas penetration into the bronchial tree. Other gases are cell toxins and can enter the deeper part of the lung before provoking irritating cough. This is what occurred for our patient who continued work in the polluted atmosphere until his severe cough obliged him to leave his job. This case is an example of cellular toxicity resulting from atmospheric gas fumes at low weakly-irritative concentrations, explaining the insidious nature of disease onset.

Research into individual predisposition to develop acute rhabdomyolysis attributed to fenoverine

A xenobiotic, well tolerated by the majority of treated patients, can cause serious complications in patients with individual susceptibility. Based on the hypothesis that such a phenomenon may occur in rare cases of rhabdomyolysis attributed to fenoverine (DCI), we designed a protocol to look for a genetic predisposition. Six patients were included who had previously had an episode of rhabdomyolysis after taking fenoverine. A seventh patient was added, who had only experienced myalgia without cytolysis. All patients were investigated by the following tests: 31-phosphorus nuclear magnetic resonance spectroscopy, histopathological examination of the muscle, muscle contraction tests and biochemical analysis of the muscle. All patients examined proved to have muscle abnormalities. The pathology found varied greatly from patient to patient: mitochondrial myopathy, lipid storage myopathy, sensitivity to malignant hyperthermia or disorders of oxidative metabolism. The probability of finding by chance such rare muscle disorders associated with the equally rare rhabdomyolysis attributed to fenoverine is practically zero. We conclude that there is a cause and effect link between underlying abnormalities and the muscular cytolysis attributed to fenoverine.

[Evaluation by poison control centers of minaprine from the modification of tablet dosages]

By 1990, the Clin Midy (SANOFI) laboratory had modified the dose of Cantor tablets: the content of active drug (minaprine) increased (50 to 100 mg). Therefore, acute intoxication by minaprine can be serious, with generalized seizures, resisting the classic treatment. We tried to evaluate the possible consequences of this change of dose for the gravity of suicide attempts. 1091 voluntary acute intoxications have been collected by the national French Poisons Centres data bank, 226 of them by the Poisons center of Marseilles. We have compared, by the chi 2 method, the frequencies of seizure and death, before and after 1990. Results are significant, confirming an increased gravity of these intoxications since the modification of dosage. Then, the laboratory reduced the number of tablets per box. We don't know if this measure will be efficient.

[Observation of illicit or misused psychotropic drugs (O.P.P.I.D.U.M.): five years of surveillance of products consumed by drug addicts at Marseille]

The aim of O.P.P.I.D.U.M. is the survey of products used by drug addicts. A five year survey, based on regular pools, has provided interesting results. 1,283 patients (80 per cent men, about 27 years old, 1/4 employed) used 2,241 drugs. The most frequent was heroin, followed by benzodiazepines, cannabis and cocaine. Flunitrazepam was the most commonly misused product, taken by users who started consumption earlier, with a higher rate of unemployment and imprisonment. Cocaine was as often taken intravenously as by sniffing, and most often used before imprisonment. Ecstasy (M.D.M.A.) has appeared recently. Codeine taken alone was used by subjects older than the heroin users, more frequently employed and virtually never prison inmates: this suggests the existence of an unofficial detoxication and substitution process. Confidence of clinicians needs anonymity of the records and return of information. Such a campaign is about to be launched.

[Value of toxicological research in newborn infants of addicted mothers by the study of several samples (urine, meconium, hair)]

BACKGROUND

Urinary detection of prenatal drug exposure in the neonate may give false-negative results. We report our experience on meconium and hair testing, in addition to urine testing in order to improve diagnosis of fetal drug exposure.

POPULATION AND METHODS

Thirty-one infants (aged 1-45 days) whose mothers were confirmed (n = 12) or suspected (n = 19) to be drug-addicted were included in the study. One or more specimens of urine, meconium or hair were collected in the 31 infants, two of the specimens in 17 and three in six. Drugs and their metabolites were detected by immunoenzymologic techniques and positive results were confirmed by gas-exchange chromatography. All the mothers and families were interviewed during admission and the information was compared to those provided by medical and social services; the results of laboratory analysis were not known by the investigators at this time of the study.

RESULTS

The maternal drug addiction was confirmed after clinical investigation in 18 cases including the 12 cases detected by prenatal interview (group 1), and recused in 13 other cases (group 2). In group 1, nine infants of 12 had a positive urine test (seven opiate, one cocaine, one cannabis), 11 of 11 a positive meconium test (nine opiate, one cocaine, one cannabis), ten of 19 a positive hair test (eight opiate, one cocaine, one cannabis); all infants in this group had at least one positive result. In group 2, all tests were negative except one urine test positive for opiate after cesarean delivery performed under anesthesia including opiate analgesia.

CONCLUSIONS

Urine, meconium and hair testing versus urine testing alone increase the sensitivity of laboratory analysis for detection of prenatal drug exposure.

[A wine pitcher, cause of lead poisoning]

A 35-year-old male nurse hospitalized for recurrent episodes of intolerable abdominal pain was found to have non-hemolytic anemia and saturnism with blood lead level reaching 500 micrograms/l. Search for the source of the lead led to the discovery of an earthenware jug purchased in a Corsica craftsware shop. This jug had been used to hold the patient's daily consumption of wine (estimated at one-half to three-quarters liters per day) in the refrigerator. On the basis of lead release measurements using the method described in the EEC directive 84/500 (maximum tolerated limit for crockery = 4 mg lead/litter contents), it was found that the jug released 216 mg/l and estimated that the patient had ingested 0.8 to 1 mg of soluble lead daily for the past 8 years. The patient was successfully treated with chelator agents. This case of lead poisoning caused by a single earthenware wine jug confirms the need for rigourous governmental directives to control the production and distribution of varnished earthenware.

[Envenomation by exotic snakes]

Snake bite envenoming in tropical areas affects an estimated one million people according to the World Health Organization. Two studies showed that annual mortality is between 30,000 and 50,000 people. Clinically cobra and viper envenoming are the most well known but several other snakes cause characteristic manifestations allowing species-specific diagnosis. Immuno-enzymatic tests are a useful diagnostic tool that is currently expanding but remains available only in developing countries because of cost. Treatment consists mainly of serotherapy in the most severe cases. Use of purified products and fragments active specifically on toxins and enzymes is both safer and more effective. Heparinotherapy should be used only when indicated by clinical manifestations and hemostasis testing. Management of envenoming must be organized in function of antivenom availabilities in a given region. Future improvements in immuno-enzymatic tests and antivenoms should allow more successful treatment of severe snake bite envenoming.

[Bradycardia during treatments of weight loss]

Sinus bradycardia was observed in 10 adolescents participating in a weight loss diet conducted in a health centre. The precise cause was assessed. The subject's age ranged from 10 to 15 years and weight loss ranged from 8 to 24 kg over a period ranging from 8 to 23 weeks. None of the subjects had taken drugs with a bradycardic effect and search for toxic agents in the blood and urine was negative in all cases. Infection was suggested since 8 of the 10 adolescents had a rhinopharyngitis a few weeks before the discovery of bradycardia. This cause was not retained due to the lack of any signs of infection or inflammation and negative virus serology. Nutritional status was therefore retained as the most likely cause in these adolescents who were eating a diet containing < or = 1350 kcal/day. This hypothesis was supported by the results of work reported in 1970 showing arrhythmia in very low calorie diets. The effect is essentially related to the biological value of proteins in the diet, its duration and the initial weight of the subjects. In addition bradycardia is frequently seen in subjects taking hypocaloric diets or with anorexia nervosa and should be considered as an adaptation to hypometabolism rather than a true heart disorder. Thus the biological value of the proteins and the mineral status should be taken into consideration during the course of low calorie diets, even though bradycardia is frequent and does not require a specific treatment. Therefore heart rate and decreasing rate of weight loss should be carefully followed during the course of low calorie diets.

[Spontaneous rupture of the spleen under ticlopidine. Apropos of two cases]

We observed two cases of spontaneous rupture of an apparently healthy spleen in two patients who were taking ticlopidine as anti-platelet aggregation treatment. The notion that the spleen was apparently healthy was based on well-defined criteria, essential for the imputability of the spontaneous lesions. In general drug-induced spontaneous ruptures of the spleen have been reported for anticoagulants but no case due to antiplatelet aggregation has been reported to our knowledge. The analysis of these two cases and a review of the recent literature suggests that ticlopidine was the causal agent in these two cases of splenic rupture.

[Latrodectism in southern France. A series of cases from the poisoning center of Marseille]

OBJECTIVES

Black widows, which belong to the genus Latrodectus, are particularly dangerous spiders. The clinical syndrome caused by their bite is known as latrodectism. In Provence and in Corsica, there is a locally-found species, Latrodectus mactans tredecimguttatus called "malmignate". A series of 30 cases were collected by the Marseille Poison centre between 1973 and 1993 inclusive.

RESULTS

The cases of poisoning involved patients bitten in the summer, mostly in Corsica (only 5 of the cases were from Provence) in rural areas. The symptoms were generally widespread pain and muscle contractions, sometimes associated with neurosomatic symptoms, such as increased sweating, or alterations in the blood pressure or body temperature. On the other hand, local signs remained benign or were absent, this sometimes causing confusion with the diagnosis: in 5 of the cases were surprisingly severe, the outcome of the poisoning was always favourable, using symptomatic treatment including infusions of calcium salts, which combat the effects of toxins (disturbance of presynaptic ion exchange).

[A surveillance method for products used by drug addicts examined in emergency units]

Products used in a toxicomaniac way are in rapid change, and different from different area. Users too have to be better known. Authors present a simple survey method of these products, based on sample use. First results seem to be correct. These method may be used, associated with others, in a network as those existent for many years in the United States.

[Benzodiazepine levels in drivers involved in traffic accidents]

A study of benzodiazepine impregnation of 234 drivers involved in road accidents showed a higher level of impregnation than that usually observed in the general population and a different frequency of this impregnation in the two populations. Although a significant correlation was found between responsibility of the driver and positivity of benzodiazepine assays, this result must be interpreted with caution and does not permit to attribute the responsibility for the accident to the presence of benzodiazepine in blood.

[Buprenorphine abuse in a series of 50 drug addicts hospitalized at a Drug Dependence Evaluation hospital in Marseille]

Buprenorphine, a synthetic central analgesic, marketed since 1987, was rapidly suspected to be subject to abuse. We tried to confirm this abuse in the context of our analytical activity at the Drug Dependence Evaluation and Information Centre. The study was based on 50 drug addicts admitted to Marseille Hospital between June and October 1992. Buprenorphine and its N-dealkylated metabolite were identified in the urine by high performance liquid chromatography equipped with a diode array detector. Nine (18%) of the 50 samples analysed were positive for buprenorphine and/or norbuprenorphine, with a confidence interval of 8 to 28%, which confirms the existence of abuse of this analgesic.

[Febrile convulsions: should some drugs be contraindicated?]

Should certain drugs be contraindicated in children who have had febrile seizures or who present a risk of convulsions? There are no publications dealing specifically with this problem. However, many drugs can induce convulsions and may be dangerous if they are associated with another determining factor (e.g. fever). Camphor known to be toxic and its use must be avoided in young children. Other terpenes given to children with colds may be convulsant if they are used for prolonged treatment or associated with other convulsant drugs (sympathomimetics, piperazine derivatives, antihistamines, etc.). On the basis of a retrospective study of 23 cases of febrile convulsion among 343 cases of infantile convulsion reported to the Poison Control Center and the Pharmacovigilance Center of Marseille between 1973 and 1991, we propose that camphor and sympathomimetics be avoided and that potential convulsant drugs and their association be used with caution. A prospective study is underway to determine responsibility of certain drugs in the occurrence of recurrence of febrile convulsions.

[Role of pharmacovigilance center in information for the public on drugs. Experience in Marseille on 9 month]

We analyzed the role of the Marseille pharmacovigilance center (working in collaboration with the local poison treatment center) in informing the general public on medicinal drugs. Over a 9-month period, the center received 115 requests from members of the public for information. 82.6% of callers were not members of the health professions and wanted information for themselves (61.7%, 67.6% women) or their children (26.08%). The questions mainly involved drug interactions (28.7%), side-effects (26%) and precautions for use in particular circumstances (20%). 178 proprietary drugs (47 of which had been bought over the counter) were mentioned. The main therapeutic classes were neuropsychiatric drugs (n = 41), cardiovascular drugs (n = 17) and analgesics (n = 16). A number of communication difficulties and problems of a deontological nature were encountered. Full information was provided in every case, together with advice on prevention to about half the callers.