[Late diagnosis of fatal invasive rickettsial disease in the Intensive Care Unit]

Mediterranean spotted fever is an infectious disease belonging to the rickettsial group due to an intracellular bacterium: Rickettsia Conorii. Pauci-symptomatic and benign forms are predominant. Severe forms are rare and increasingly reported in the recent literature with potentially life-threatening severe multi-systemic involvement. We here report a very rare case of a 52-year old patient admitted to an Intensive Care Unit with convulsions, septic shock and acute renal failure. On the second day, given the discovery of « inoculation chancre »-like lesions which needed to be treated, the diagnosis of severe rickettsial disease with severe multivisceral involvement was suspected and then confirmed by serology. Antibiotic treatment with doxycycline was then administered. However the patient developed acute tubular necrosis requiring extrarenal purification sessions. The patient rapidly developed fatal multivisceral failure. Rickettsiosis is associated with microcirculatory vasculitis thus leading to severe clinical manifestations. The mechanisms involved and the possible prognostic factors have been discussed in this study through a review of the literature.

[Postoperative necrotizing fasciitis: a rare and fatal complication]

Les complications pariétales post opératoire peuvent être exceptionnellement majeures et graves menaçant le pronostic vital. La fasciite nécrosante est une infection rare de la peau et des tissus sous-cutanés profonds, se propageant le long des fascias et du tissu adipeux. Elle est surtout causée par le streptocoque du groupe A Streptococcus pyogènes mais également par d'autres bactéries telles que Vibrio vulnificus, clostridium perfringens ou Bacteroides fragilis. La fasciite nécrosante est une véritable urgence médicochirurgicale. Nous rapportons dans ce travail une observation très rare d'une gangrène pariétale abdominale survenant chez une patiente de 75 ans au cinquième jour post-opératoire d'un kyste de l'ovaire. L’évolution était marquée par l'installation d'un état de choc septique réfractaire rapidement fatal à J3 de la prise en charge.

[The lithiasic acute cholecystitis: laparoscopic treatment (About 106 cases)]

AIM

To assess the feasibility and the advantages of the coelioscopy in the treatment of the acute cholecystitis.

METHODS

From January 1996 to December 2001, 106 laparoscopic cholecystectomies for acute cholecystitis have been collected. The diagnosis of acute cholecystitis has been confirmed for all cases by the pathologic exam.

RESULTS

These 106 cases represent 12.4% of the set of the laparoscopic cholecystectomies practiced during the same period of survey. They are 78 women and 28 men. The mean age was 51.7 years. Eight patients (7.6%) presented an elevated operative risk (ASA III). The diagnosis of acute cholecystitis has been kept before operation in 45.3% of the cases. Major or minor intraoperative incidents have been observed in 18.9% of the cases. The rate of conversion was 17%. The reasons are dominated by the difficulties of dissection in 10 cases (55.5%) and hemorragea in 6 cases. The research of the predictive factors of conversion found 5 factors, the hyperleucocytosis, the operative delay superior to 72 hours, the adhesions around the gallbladder, the gangrenous gallbladder and the pediculitis. The post operative mortality was nul. The morbidity rate was 12.3%. Among the 13 patients who had postoperative complications, 8 were after conversion.

CONCLUSION

These results showed that the laparoscopic cholecystectomy for acute cholecystitis is an effective and good alternative with acceptable morbidity that should decrease with learning curve.

[Cystic lymphangioma of the pancreas: an exceptional location]

Cystic lymphangioma of the pancreas is a rare benign vascular tumor. Its histogenesis is still hypothetical and preoperative diagnosis is difficult. We report a new case in a 14-year-old girl hospitalized for pain in the epigastrium and vomiting. Radiologic findings concluded in a cystic tumor of the head of the pancreas. The mass was completely excised. The pathological examination of the surgical specimen revealed cystic formations whose wall consisted of a squamous endothelial epithelium on a fibrous tissue and a few scattered lymphoid clusters, arguing in favor of a cystic lymphangioma.

[Intrauterine device and pelvic tumor: two case reports of pelvic actinomycosis with pseudotumor from tropical zones]

Pelvic actinomycosis is a rare chronic disease caused by actinomycete species. The pseudotumorous form is the most common and often leads to misdiagnosis. The purpose of this report is to describe two cases of pelvic actinomycosis involving women with a history of intrauterine contraceptive device (IUD) use. Diagnosis was based on pelvic mass and the findings of surgery undertaken for suspicion of an advanced ovarian tumor with hepatic metastasis in one case and for a tumor of the right ovary in the other case. Diagnosis was confirmed by histological examination of a biopsy specimen in the first case and of the surgical specimen (right ovariectomy) in the second case. Long-term antibiotic therapy was effective in both patients. Based on these two cases and review of the literature, discussion focuses on diagnostic pitfalls, natural course, and therapeutic options for this particular infection.

[Pelvic pseudotumoral actinomycosis: two cases]

INTRODUCTION

Pelvic actinomycosis is a rare suppurative disease that should be included in the differential diagnosis of gynecological cancers.

CASE REPORTS

We report two women aged 40 and 41 years with pelvic tumor-like actinomycosis. Physical examination disclosed a pelvic mass in both cases. CT-scan showed annexial infiltrative tumor in both cases with liver metastasis and peritoneal carcinosis in one case each. Surgical procedure consisted in right annexectomy in one case and peritoneal biopsy in the other. Pathologic diagnosis was diagnostic of actinomycosis. Both patients were treated by penicillin G 20 million IU/day during two weeks and then by amoxicilline 3g/day per day during six months. Clinical outcome showed significant improvement in both cases with complete regression of hepatic and pelvic lesions on CT-scan in one case.

CONCLUSION

Pelvic actinomycosis is a rare suppurative disorder, commonly associated with a long term wearing of intra-uterine device. Diagnosis is difficult, often delayed and pelvic actinomycosis could mimic gynaecologic neoplasia.

[Complications of Meckel's diverticulum. Report of 42 cases]

AIM

Our aim was to report the main complications of the Meckel's diverticulum.

METHODS

Our retrospective study concerns 42 cases of complicated Meckel's diverticulum, collected during one period of 18 active years from January 1988 to December 2005. The yearly impact is 2,33 cases/year. We excluded the asymptomatic Meckel's diverticulum, of fortuitous discovery during intervention.

RESULTS

The middle age of our patients is 25 years, with extremes going from 2 to 74 years. The sex-ratio is 3,2. The diagnosis before intervention of the complicated Meckel's diverticulum was not evoked in any time. The clinical features were an acute intestinal closure in 22 cases, an appendicitis in 13 cases, an appendicular peritonitis in 6 cases, and an acute intestinal intussusceptions in one case. In any case, it is the surgical exploration that permitted to confirm the diagnosis of a complicated Meckel's diverticulum. The approach way was median in 27 cases, MacBurney in 13 cases, and laparoscopic in 2 cases. The surgical exploration showed peritonitis in 16 cases, one diverticulitis in 23 cases, an acute intestinal intussusception in one case, a tumour in one case, and haemorrhagic diverticulum's ulcer in one case. The treatment consisted in a segmental resection of ileum with end to end anastomosis (37 cases) and a cuneiform resection (5 cases). The histological exam showed heterotopy of gastric tissue in 12 cases, of pancreatic tissue in two cases, and a Burkitt's lymphoma on a diverticulum in one case. We noted a precocious death following a septic shock.

CONCLUSION

The Meckel's diverticulum constitutes a most common benign malformation of the digestive tube. The prognosis is related extensively to the gravity of its complications that can benefit, not only of the contribution of the laparoscopic diagnosis, but also therapeutic.

[Extrahepatic cholestasis secondary to Castleman's disease]

Castleman's disease is a rare lymphoproliferative disorder of unknown etiology with different clinical manifestations. A 76-year-old man presented with pruritus and jaundice, a cholestasis and an increase of acute phase reactants. Peroperative investigations evidenced a 3-cm lymphadenopathy that compressed the biliary duct. Diagnosis of multicentric Castleman's disease was confirmed by the histologic examination of the lymphadenopathy. HIV testing was negative. Corticosteroid therapy was started and partially controlled the disease.

The significance of the HBeAg/anti-HBe system in hemodialysis patients. A multicenter study

The HBeAg/anti-HBe system was studied as a marker of infectivity and chronic progressive liver disease in 460 hemodialysis patients. The importance of HBeAg as an index of infectivity was confirmed in that it was present simultaneously with specific DNA polymerase (31 patients) and by the presence of widely diffuse core particles in the hepatocyte nuclei (revealed by biopsy in six patients). In contrast, HBeAg showed no useful correlation with progressive liver disease, the absence of which was confirmed in all cases by biochemical and histological studies.