High prevalence of infectious events in thrombotic thrombocytopenic purpura and genetic relationship with toll-like receptor 9 polymorphisms: experience of the French Thrombotic Microangiopathies Reference Center

BACKGROUND

Infectious events have been reported as major environmental triggers of thrombotic thrombocytopenic purpura (TTP). We detail here the potential association between infections and TTP.

STUDY DESIGN AND METHODS

We recruited randomly and prospectively a cohort of 280 consecutive TTP patients during a 9-year period. Features of infection were systematically recorded.

RESULTS

Features consistent with an infectious event were observed in 114 patients (41%) at time of TTP diagnosis. Infectious agents were documented in 34 cases and were mainly Gram-negative bacilli. At time of diagnosis infected patients more frequently had fever (p < 0.001). Infections at diagnosis did not impact prognosis and outcome. Thirty-six percent of patients experienced an infectious event during hospitalization, which resulted in more exacerbation of TTP (p = 0.02). Infections were not overrepresented during treatment in patients who received steroids and/or rituximab. Further genetic analysis of toll-like receptor (TLR)-9 functionally relevant polymorphisms revealed that TLR-9 +2848 G and TLR-9 +1174 A genotypes were more frequent in TTP patients than in controls (p = 0.04 and p = 0.026, respectively) and more particularly in patients negative for the Class II human leukocyte antigen system susceptibility allele DRB1*11 (p = 0.001 and p = 0.002, respectively). Haplotypes estimation showed that 1174A-2848G haplotype was significantly more frequent in TTP (p = 0.004), suggesting a primary role for this haplotype variation in conferring a predisposition for acquired TTP.

CONCLUSION

Infections should be considered as an aggravating factor during the course of TTP. Particular polymorphisms in TLR-9 gene may represent risk factors for TTP.

Development and validation of a predictive model for death in acquired severe ADAMTS13 deficiency-associated idiopathic thrombotic thrombocytopenic purpura: the French TMA Reference Center experience

BACKGROUND

Acquired thrombotic thrombocytopenic purpura is still associated with a 10-20% death rate. It has still not been possible to clearly identify early prognostic factors of death. This study involved thrombotic thrombocytopenic purpura patients with acquired severe (<10% of normal activity) ADAMTS13 deficiency and aimed to identify prognostic factors associated with 30-day death.

DESIGN AND METHODS

The study involved a prospective cohort of patients and was carried out between October 2000 and August 2010. A validation cohort of patients was set up from September 2010 to August 2011. Altogether, 281 (analysis cohort) and 66 (validation cohort) consecutive adult thrombotic thrombocytopenic purpura patients with acquired severe ADAMTS13 deficiency were enrolled. The study evaluated 30-day mortality after treatment initiation according to characteristics at inclusion.

RESULTS

Non-survivors (11%) were older (P=10(-6)) and more frequently presented arterial hypertension (P=5.10(-4)) and ischemic heart disease (P=0.013). Prognosis was increasingly poor with age (P=0.004). On presentation, cerebral manifestations were more frequent in non-survivors (P=0.018) and serum creatinine level was higher (P=0.008). The most significant independent variables determining death were age, severe cerebral involvement and LDH level 10 N or over. A 3-level risk score for early death was defined and confirmed in the validation cohort using these variables, with higher values corresponding to increased risk of early death.

CONCLUSIONS

A risk score for early death was defined in patients with thrombotic thrombocytopenic purpura and validated on an independent cohort. This score should help to stratify early treatment and identify patients with a worse prognosis.

Predictive features of severe acquired ADAMTS13 deficiency in idiopathic thrombotic microangiopathies: the French TMA reference center experience

Severe ADAMTS13 deficiency occurs in 13% to 75% of thrombotic microangiopathies (TMA). In this context, the early identification of a severe, antibody-mediated, ADAMTS13 deficiency may allow to start targeted therapies such as B-lymphocytes-depleting monoclonal antibodies. To date, assays exploring ADAMTS13 activity require skill and are limited to only some specialized reference laboratories, given the very low incidence of the disease. To identify clinical features which may allow to predict rapidly an acquired ADAMTS13 deficiency, we performed a cross-sectional analysis of our national registry from 2000 to 2007. The clinical presentation of 160 patients with TMA and acquired ADAMTS13 deficiency was compared with that of 54 patients with detectable ADAMTS13 activity. ADAMTS13 deficiency was associated with more relapses during treatment and with a good renal prognosis. Patients with acquired ADAMTS13 deficiency had platelet count <30×10⁹/L (adjusted odds ratio [OR] 9.1, 95% confidence interval [CI] 3.4–24.2, P<.001), serum creatinine level ≤200 µmol/L (OR 23.4, 95% CI 8.8–62.5, P<.001), and detectable antinuclear antibodies (OR 2.8, 95% CI 1.0–8.0, P<.05). When at least 1 criteria was met, patients with a severe acquired ADAMTS13 deficiency were identified with positive predictive value of 85%, negative predictive value of 93.3%, sensitivity of 98.8%, and specificity of 48.1%. Our criteria should be useful to identify rapidly newly diagnosed patients with an acquired ADAMTS13 deficiency to better tailor treatment for different pathophysiological groups.

Cancer awareness in atypical thrombotic microangiopathies

OBJECTIVE

To specify the clinical and biological characteristics of thrombotic microangiopathies (TMAs) associated with a recent diagnosis of cancer. PATIENTS AND Methods. Multicenter study involving 14 national centers. Cross-sectional analysis of 20 patients with cancer-associated TMAs included in our national registry from October 2000 to July 2007. Patients were also compared with 134 adult patients with an acquired idiopathic TMA by univariate analysis.

RESULTS

Patients with a cancer-associated TMA typically displayed severe weight loss, dyspnea, bone pain, as well as disseminated intravascular coagulopathy and massive erythromyelemia (75%, 55%, 50%, 41%, and 85% of cases, respectively). By contrast, these features were observed with a much lower incidence in patients with an idiopathic TMA (8.9%, 19.7%, 0.8%, 7.1%, and 17.5%, respectively). Moreover, median platelet count was higher (48 x 10(9)/l; range, 21-73 x 10(9)/l versus 19 x 10(9)/l; range, 10-38 x 10(9)/l, respectively) and median serum creatinine level was lower (74 microM [range, 68-102] versus 113 microM [range, 80-225], respectively). The activity of the specific von Willebrand factor-cleaving proteinase ADAMTS13 was detectable in 14/17 studied patients. Platelet count improvement was observed in only seven patients and paralleled the response to chemotherapy. Prognosis of patients with cancer-associated TMAs was very poor, with a 30-day and 2-year mortality rate of 50% and 95%, respectively.

CONCLUSION

Cancer-associated TMAs display specific features at onset that should prompt investigation of an underlying disseminated malignancy. In this context, chemotherapy rather than plasma is mandatory since TMA prognosis parallels that of cancer.

Diagnosing Treponema pallidum in Secondary Syphilis by PCR and Immunohistochemistry

Epidemiological aspects of syphilis in Western countries have undergone a significant change with respect to the number of cases. Detection of Treponema pallidum is difficult, and the correct diagnosis of secondary syphilis can be critical. In this study, biopsy samples from skin lesions of 12 patients with secondary syphilis were used. Diagnosis of syphilis was based on clinical presentation, dark-field microscope analysis, and serological tests. Using a polyclonal antibody directed against T. pallidum, we show the presence of T. pallidum in 90% of the samples studied with the bacteria located in the epidermis and the upper dermis. The T. pallidum 47-kDa surface protein gene could be amplified by PCR in 75% of the skin lesions. When combining both techniques, T. pallidum was detected in 92% of the samples from patients with secondary syphilis but not in the control samples. Our work suggests that both immunohistochemistry and PCR could be useful for the diagnosis of secondary syphilis and may be helpful in some rare cases when serological assays failed to detect T. pallidum antibodies.

Scurvy in liver transplant patients

We report on scurvy in 3 liver transplant recipients. Clinical presentation was limited to ecchymotic purpura and mild follicular keratosis with no mucosal involvement. Skin biopsies suggest vitamin C deficiency, which was confirmed by a low level of vitamin C in both sera and leukocyte specimens. Skin lesions dramatically improved within a few weeks after supplementation with ascorbic acid.

Evaluation of Coleman Lipostructure for Treatment of Facial Lipoatrophy in Patients With Human Immunodeficiency Virus and Parameters Associated With the Efficiency of This Technique

OBJECTIVE

To evaluate the efficiency of Coleman lipostructure in patients infected with human immunodeficiency virus (HIV).

DESIGN

Open-label study and survey.

SETTING

Ambulatory dermatosurgery department of a university hospital.

PATIENTS

Thirty-three consecutive HIV-infected patients undergoing Coleman lipostructure between 2000 and 2001.

INTERVENTIONS

Clinical examination, blood tests, and standardized photographs at baseline and 1 year after the lipostructure.

MEAN OUTCOME MEASURES

Efficiency was assessed by the agreement of 3 independent medical specialists on facial lipodystrophy improvement after surgery and by patient satisfaction.

RESULTS

Facial lipoatrophy was improved in 12 patients (36%; 95% confidence interval, 20%-52%) as judged by all 3 evaluators. Quantity of fat injected (P = .01) and a low serum triglyceride level before surgery (P = .03) were significantly associated with improvement of facial lipoatrophy. Of the 33 patients, 14 (43%) were very satisfied, 17 (50%) were partly satisfied, and 27 (81%) had a better quality of life. The most common comment was that the patient looked better and appeared less ill.

CONCLUSION

Our 1-year evaluation of Coleman lipostructure for correction of facial lipoatrophy in HIV-infected patients proved the efficiency of this treatment when measured conservatively by agreement on improvement by 3 independent specialists and demonstrated a patient satisfaction rate of 93%.

Mitochondrial DNA depletion in adipose tissue of HIV-infected patients with peripheral lipoatrophy

BACKGROUND

NRTI-induced host toxicity is proposed to involve cellular mitochondrial DNA (mtDNA) depletion. Determinants of cellular mtDNA copy number from HIV-infected patients receiving HAART and HIV-seronegative controls were investigated from subcutaneous fat samples, and relation with antiretroviral regimen was studied.

STUDY DESIGN

HIV-infected patients receiving HAART (n = 50), HIV-infected patients not currently under HAART regimen (n = 2) and HIV-seronegative controls (n = 9) of similar age and BMI were enrolled prospectively when undergoing Coleman's lipostructure for correction of facial lipoatrophy or plastic surgery, respectively. After centrifugation, abdominal fat tissue was collected and stored at -80 degrees C. MtDNA analysis was blindly performed after a total DNA extraction from adipose tissue, followed by a real-time PCR quantification. The log of mtDNA copies/cell in adipose tissue [log(DNA)] was compared between groups by means of analysis of variance.

RESULTS

The log(DNA) in adipose tissue of HIV-infected patients was significantly lower than in the HIV-seronegative control group (P < 0.0001). In HIV-infected patients, log(DNA) was significantly reduced in the 50 NRTI-treated patients (P < 0.01), but not when considering mtDNA level according to the use of PI or NNRTI in current HAART regimen. In NRTI-treated patients, only stavudine (n = 20) and didanosine (n=14) were significantly and independently associated with reduced mtDNA level (P < 0.0001 and <0.05, respectively). Currently stavudine or didanosine-treated patients had a significant reduced mtDNA level compared to past users (P < 0.0001 and <0.05, respectively). Other clinical, biological, and immuno-virological variables than NRTI did not correlate significantly to adipocyte mtDNA level.

CONCLUSION

This study supports that current treatment by NRTI is a main determinant of mtDNA depletion in adipose tissue of HIV-seropositive patients with peripheral fat wasting. Stavudine or didanosine current intake is significantly associated with mtDNA depletion in vivo, that could be reversible after the discontinuation of these molecules, when considering mtDNA level according to current use versus past use of these molecules.

Mycosis Fungoides-Type Cutaneous T-Cell Lymphoma and Neutrophilic Dermatosis

BACKGROUND

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma (CTCL). Patients with limited patch and/or plaque disease have a normal life expectancy. Neutrophilic dermatosis (ND) may be associated with various hematologic disorders. However, its association with CTCL is exceptional and has been reported only twice with leukemic forms of CTCL.

OBSERVATIONS

Three patients with MF developed ND resistant to conventional therapies and responsible for an impaired quality of life due to constitutional symptoms and painful cutaneous lesions. All patients underwent an aggressive treatment course despite their varying initial clinical stages of MF, and all experienced a fatal outcome less than 18 months after the onset of ND.

CONCLUSIONS

The association of MF with ND is exceptional and carries a poor prognosis, but the pathophysiologic nature of this association remains unclear. It may involve neutrophil chemoattractant cytokine production by tumor cells. A triggering role of interferon alfa is also possible.

Cutaneous Waldenström's macroglobulinemia with “deck-chair” sign treated with cyclophosphamide

Specific skin lesions are rare in Waldenstrom's macroglobulinemia (WM). We report a case of a 58-year-old man who presented macules, papules, and an erythema of the trunk with the "deck-chair" sign revealing the relapse of WM. Histologic and immunohistochemical examinations confirmed that cutaneous lesions were related to specific infiltration with neoplastic cells. Remission of both skin lesions and immunological abnormalities was obtained with oral cyclophosphamide.

Plasmocytomes cutanés associés au virus Epstein-Barr chez les transplantés d’organes

BACKGROUND

Post-transplantation lymphoproliferative disorders develop in 1 to 10p. 100 of organ transplant recipients and are frequently associated with Epstein-Barr virus (EBV). Among post-transplantation lymphoproliferative disorders, plasmacytoma with cutaneous involvement is exceptional. Association with EBV has been rarely reported in post-transplantation plasmacytomas and the latency type of EBV has never been characterized. We report 2 new cases of cutaneous monotype EBV-related plasmacytomas.

CASE-REPORTS

Clinical presentation was a sub-cutaneous tumor on the thigh in the first case and an ulcerated nodule of the leg in the second case, occurring respectively 7 and 8 years after organ transplantation (liver transplantation and heart transplantation). In both lesions, tumor cells exhibited lambda light chain restriction and the association with EBV was confirmed using immunohistochemistry and in situ hybridization. The expression of EBV genes in tumor cells demonstrated type III latency.

DISCUSSION

The classification of post-transplantation lymphoproliferative disorders is not well defined and some authors retain 3 categories. Among the latter, plasmacytomas have been rarely described. Cutaneous involvement is reported in 4 cases and an association with EBV in only 2 cases without description of viral latency. Clinical and histological features of post-transplantation plasmacytomas appear polymorphic. We report EBV-association in both cases, with a type III latency clearly demonstrated in one case, as has been reported in other lymphoproliferative diseases in patients with congenital or acquired immunodeficiency. We also discuss various possible therapeutic strategies for post-transplantation lymphoproliferative disorders.

[Clinical management of non palpable breast lesions: experience about a series of 176 consecutive cases]

OBJECTIVE

To propose a rational attitude to treat infraclinic breast lesions about a 176-case retrospective analysis.

PATIENTS AND METHODS

Between January and December 2000, 176 patients were addressed for an infraclinic breast lesion. The epidemiologic and mammographic data, diagnostic management and histological results were collected.

RESULTS

Patients were addressed for an ACR 2 lesion in 0.8% of cases, ACR 3: 34.8%, ACR 4: 43.2% and ACR 5: 21.2%. One hundred and sixteen patients underwent a stereotactic macrobiopsy: 55 Advanced Breast Biopsy Instrumentation (ABBI), 61 Minimal Invasive Breast Biopsy (MIBB). Histologically, 59.5% were benign, 33.6% malignant, 2.6% borderline and 4.3% suspicious or non contributive. Forty-two patients underwent an open surgical biopsy. Histologically 56.1% were benign, 41.5% malignant and 2.4% borderline. Eighteen patients were controlled by mammography. Among ACR 3s there were 90% of benign lesions and 46% of malignancy in ACR 4s. Patients with malignant, borderline or suspicious result in stereotactic biopsy, underwent one-time surgery in 97% vs 55% in surgical biopsy (P < 0.0001).

DISCUSSION AND CONCLUSION

Infraclinic breast lesions must be radiologically classified with the ACR classification. Stereotactic macrobiopsies are reserved for ACR 4 and ACR 5 lesions. Because of their reliability, practice of macrobiopsies avoids surgery in about 50% of ACR 4 lesions which correspond to benign lesions. When the result is malignant, it allows most of times surgical procedure one-time.

Detection and quantification of Mycoplasma genitalium in male patients with urethritis

Detection and quantification of Mycoplasma genitalium were evaluated in 83 patients with urethritis (group 1), 60 patients with urethral symptoms but no urethritis (group 2), and 50 asymptomatic men (group 3). Quantification of M. genitalium was carried out using real-time polymerase chain reaction (PCR) analysis of first-pass urine samples. The rate of detection of M. genitalium was significantly higher in group 1 than in groups 2 and 3 (P<.0001). The mean observed concentration of M. genitalium was 1.2x10(4) equivalent genomes/mL of urine (range, 50 to 8x10(4) equivalent genomes/mL). Analysis of M. genitalium load in serial urine samples collected before and after the administration of antibacterial treatment showed an association between clinical and microbiological responses, with a shift to negative PCR results in symptom-free patients. Our results illustrate the usefulness of monitoring the M. genitalium load in evaluating the susceptibility of M. genitalium to antibacterial treatment.

[Management of psychologic factors in chronic urticaria. When and how?]

INTRODUCTION

Chronic idiopathic urticaria is a frequent disease witch treatment is often disappointing. Psychological factors seem to be frequently associated to it. In what cases consider psychological treatment? And according to what modalities?

METHOD

Review of the literature in search of articles in both French and English concerning psychological factors associated to chronic urticaria, either as responsible factors, or as aggravating factors, or as a consequence of the urticaria, with the study of the impact on the quality of life. We also studied articles analyzing various types of psychology-targeted treatments. We use a serie of keywords on following data banks: Medline (1970-2002), Embase, Pascal and Cochrane Library (period 1995-2002).

RESULTS

Very few controlled studies were published.: Various studies are found reporting an association between stress, anxiety or depressive symptomatology and CIU, but none can assert a causality. Three controlled opened studies show significantly more anxiety and\or depression in the chronic urticaria patients. Three studies analyze the psychopathological personalities of the patients with urticaria. Two studies focus specifically on the impact of the CIU on the quality of life. Various psychotropic drugs (mainly tricyclic antidepressants) have been tested, mostly because of their anti-H1 activity. There is no study on psychological support, psychotherapies, behavioral therapies, technique of biofeedback and group therapies. A particular attention is focused to hypnosis and relaxation techniques because of the improvement of the urticarial wheals reported in studies of cutaneous ability to react in subcutaneous injections of histamine.

CONCLUSION

A complementary psychological treatment of patients suffering from CIU seems necessary, because of the high frequency of psychological symptoms. Published studies concern essentially the prescription of psychotropic drugs and the use of therapies with suggestion or relaxation under hypnosis. Prospective studies on the impact of an adapted psychological treatment on the CIU evolution are not available.

Current treatments for scabies

Scabies is a frequent interhuman ectoparasitic infection. Several treatments are available worldwide. There are local treatments: synthetic pyrethrins, benzyl benzoate, lindane, crotamiton. Recently a few studies were published concerning ivermectin, systemic antiparasitic agent use in onchocercosis treatment. We reviewed the literature with an evidence-based medicine method. We attempt to answer two questions in particular: what is the treatment of choice for common scabies in a patient otherwise in good health? What is the role of systemic ivermectin? We also report specific situations. Among local treatments, studies are heterogeneous according to products, countries, group of treated patients, with or without contact subjects, and the method of treatment application. There are very few high proof-level controlled studies. In France, a combination of benzyl benzoate 10% and sulfiram 2% is used most, according to professional consensus. The most studied product is the cream permethrin 5%, available in the USA and UK. Its efficacy seems slightly superior to lindane and less toxic. It is more efficient than crotamiton. There is no study comparing benzyl benzoate and permethrin. Concerning systemic ivermectin, five controlled studies showed its efficiency in common scabies. But its relative efficiency over local treatment has not been established. A few open studies showed its efficacy in institutional epidemic, profuse scabies and in HIV-positive patients. Local treatment of choice in common scabies remains to be determined among the four principal molecules. There is no study comparing permethrin or esdepallethrin to benzyl benzoate. In what cases should we prescribe crotamiton or lindane? Indication of ivermectin seems proved in common scabies and probably for HIV-positive patients. It remains to be determined if it should be prescribed in the first instance, be double or triple, be associated or not with local treatment. In case of keratotic scabies, ivermectin seems interesting with two applications within 1 week, and should be associated with local treatment (duration remains to be defined). Ivermectin is probably useful in institutional epidemic, and therapeutic attitude remains to be defined. Ivermectin seems to have little or no risk. Treatment must be adapted case-by-case, according to feasibility. It is still important to treat contacts, and modality of this treatment remains to be specified.

HIV and antiretroviral drug distribution in plasma and fat tissue of HIV-infected patients with lipodystrophy

OBJECTIVE

To determine HIV and antiretroviral drug distribution in plasma and fat tissue of HIV-infected patients with lipodystrophy.

METHODS

Twenty-three consecutive HIV-infected patients (median age, 43 years; male:female ratio, 18:5; median CD4 cell count, 419 x 10(6)/l) undergoing Coleman's lipostructure were enrolled prospectively in this study. HIV-1 RNA and plasma concentration of antiretroviral drugs were determined blindly in plasma and adipocyte lysate samples. HIV-1 proviral DNA was detected by nested PCR in fresh frozen adipocytes.

RESULTS

Mean plasma HIV-1 RNA was significantly higher than that in adipocyte lysate samples (this was below the limit of detection in all patients tested). HIV-1 proviral DNA was positive in two out of 18 adipocyte samples with a level between 2 and 5 copies; the distribution seemed to be specific and comparable within each therapeutic class--protease inhibitors (PI) or non-nucleoside reverse transcriptase inhibitors (NNRTI). NNRTI concentrations in adipocyte lysates were approximately 100-fold higher than those of PI. Efavirenz may accumulate in fat tissue as a function of treatment duration.

CONCLUSION

Our results suggest that HIV does not replicate and does not integrate its genome in fat tissue in patients with fat redistribution abnormalities. In patients with effective nadir plasma concentrations of PI and NNRTI, determination of concentration in adipocyte lysates suggests that PI may diffuse in fat tissue with the same pattern of distribution for all structurally related components tested. NNRTI present a high affinity for fat tissue and may accumulate in this compartment.

[Buschke-Lowenstein penile tumor]

The Buschke-Löwenstein genital tumour is a poorly defined, uncommon tumour. The distinction between benign lesions, potentially malignant lesions and carcinomatous lesions is difficult. The authors report a case of Human Papillomavirus (HPV) 11-associated Buschke-Löwenstein tumour with an area of micro-invasive carcinoma on histological examination of the surgical resection specimen. A 34-year-old patient was operated for recurrent condylomatous lesions of the penis with scrotal extension. Histological examination of the complete operative specimen confirmed the presence of Buschke-Löwenstein tumour as well as an area of dermal micro-invasion on one section. Molecular hybridization revealed the presence of HPV 11 DNA and immunohistochemistry showed basal cells weakly expressing mutant p53. The classification of Buschke-Löwenstein tumours is controversial. Some authors consider these tumours to be benign tumours or giant condylomata (non-metastatic, associated with HPV 6-11), while others consider these tumours to be borderline malignant (local extension and risk of progression to invasive carcinoma). The role of HPV as cofactor involved in carcinomatous transformation also remains controversial. The authors emphasize the need for surgical resection of this type of tumour with histological examination of the entire operative specimen looking for areas of micro-invasion. In the presence of micro-invasion with healthy resection margins and staging by clinical examination and complementary investigations, treatment essentially consists of regular surveillance.

3-Anilino-4-arylmaleimides: potent and selective inhibitors of glycogen synthase kinase-3 (GSK-3)

Potent 3-anilino-4-arylmaleimide glycogen synthase kinase-3 (GSK-3) inhibitors have been prepared using automated array methodology. A number of these are highly selective, having little inhibitory potency against more than 20 other protein kinases.

[Stereotactic excisional nonpalpable breast lesions using the advanced breast biopsy instrumentation]

Today, the widespead use of mammography has increased the detection of suspected nonpalpable lesions. Accordingly, the number of surgical biopsies is higher.

PURPOSE

Evaluation of Advanced Breast Biopsy Instrumentation (ABBI) system as a promising alternative to conventional surgical biopsy in stereotactic excisional breast biopsies less than 20 mm.

METHODS

From October 1998 and May 1999, 33 women have had: stereotactic excisional breast biopsies less than 20mm using ABBI. Epidemiologic, mammographic and histologic datas were collected.

RESULTS

Mammographic finding were 23 microcalcifications and 10 nonpalpable solid nodular densities. In 25 cases, pathology were benign (79%), 7 cases (21%) were cancer. In these cases, the cancer could be treated later, with a single surgical procedure. No complication occurred and tolerance was excellent in most cases.

CONCLUSION

Stereotactic excisional breast biopsies less than 20 mm using ABBI is a very good alternative (reliable, reproducible, ambulatory, very weak morbidity) to surgical biopsy.

Recurrent convulsions and cardiac conduction disturbances after propafenone overdose

Propafenone is a class Ic antiarrhythmic agent which also exhibits beta-adrenergic and fast sodium channel blockade. We report a case of severe poisoning in a 24-y-old woman who suffered a seizure 1 h after the intentional ingestion of 2.7 g propafenone, and had a recurrence of convulsion on arrival at the hospital. She also developed severe arrhythmia during her hospital course. She recovered uneventfully with supportive treatment.

Gamma butyrolactone poisoning and its similarities to gamma hydroxybutyric acid: two case reports

Clinical experience with toxicity induced by products containing gamma butyrolactone is limited. We report here 2 cases of gamma butyrolactone poisoning with a nail polish remover labelled "acetone-free". Rapid onset of coma, respiratory depression and bradycardia occurred in both patients. After supportive care, they fully recovered within a few hours.

[Acute psychiatric syndrome and quinolones]

A case of Flumequine poisoning is described; a 13-year-old girl was admitted for a psychiatric syndrome. 3 hours after, seizures, coma, and metabolic disorders were observed. Infectious, encephalitic or diabetic diseases were suspected, but not confirmed. After 12 hours of a symptomatic treatment, the clinical status improved and the patient was discharged. At that time a tablet was found in her bedroom and a mas spectrographic analysis was positive for Flumequine. This case report is in agreement with previous observations and confirms the small therapeutic index of quinolone, and the absolute necessity to assess carefully a psychiatric diagnosis.

Severe ethylene glycol butyl ether poisoning. Kinetics and metabolic pattern

A case of severe poisoning with ethylene glycol butyl ether (EGBE) after massive ingestion is described. Deep coma, metabolic acidosis, hypokalaemia, haemoglobinuria, oxaluria and a transitory rise in the serum creatinine level were observed. The elimination of the various metabolites butoxyacetic acid and oxalate was assessed in urine and a metabolic pattern for EGBE is suggested.

[Subperiosteal metastasis of esophageal adenocarcinoma]

The authors report an observation of a tibial subperiosteal metastasis of an esophageal cancer. Subperiosteal metastases are rare, appearing on plain radiography as a cortical lysis of a long bone with a "saucer" aspect. They were considered specific of a bronchogenic carcinoma. To the best of our knowledge this is the second observation of subperiosteal metastasis, whose primary tumor is not a broncho-pulmonary cancer.

Delayed excision of a defect after free omental transfer with uncertain viability; a case report

We present the case of a 45-year-old man with an extensive radionecrotic ulcer of the anterior aspect of the thigh and exposure of the femur. Difficulty in the revascularisation of a free omental transfer due to radiation damage to the recipient vessels led us to delay excision of the defect and to store the flap temporarily in a plastic bag close to the recipient site; 48 hours later its satisfactory appearance allowed excision of the defect and successful final inset of the omentum. Advantages of this procedure are discussed.

The lateral arm flap: an anatomic study

The anatomy of the lateral arm flap is further elucidated, and the surgical techniques involved in raising the flap are described in detail. The data are derived from studies in 25 cadavers and five clinical cases. The relative merits of this versatile free flap are discussed. Three clinical cases are cited for illustration.