P09.05 Treatment strategy of MRI postcontrast non-enhanced gliomas

BACKGROUND

MRI postcontrast nonenhanced brain tumors are found benign biologic entities with the better prognosis. The aim of this paper is to evaluate predictive features on MRI considered definite diagnosis occurrence, tumor progression, upgrading and postcontrast enhancement evolution on follow-up serial MRI.

MATERIAL AND METHODS

We retrospectively collected patients with the initially MRI postcontrast nonenhanced brain tumors, treated in our hospital from January 2009 to June 1, 2006. All tumors were converted into WHO 2016 IDH status classifications in accordance with current recommendations. Information about surgeries, patient clinical condition, MRI, and results of histological, immunohistochemical, molecular genetic, and cytogenetic investigations were gathered. Semiautomatic segmentations were performed using FSLeyes software (part of FSL package) on preoperative and followed-up 3D T1-w MPRAGE, T2-w or FLAIR scans. We focused on residual tumor volume, and time distribution of T2/FLAIR changes and T1-w postcontrast enhancement evolution.

RESULTS

Seventy-eight patients were enrolled in this study. There were 47 gliomas grade II 22 grade III and 9 grade IV. Glioma II comprised 35 diffuse astrocytomas (23 patients had IDH1 mutation). Nine gliomas grade III and 6 gliomas grade IV had IDH1 mutation. Overall survival in glioma group grade II, grade III, grade IV was 187.9 months, 71.1 months and 25.2 months, respectively. Oncotherapy underwent 14 gliomas grade II after first surgery, 13 patients had radiotherapy a 1 patient had neoadjuvant chemotherapy. Seventeen gliomas grade III were indicated to oncotherapy, 5 patients had radiotherapy and 12 had chemoradiotherapy. All patients with glioma grade IV experienced oncotherapy. Time to progression of non-contrast enhanced brain tumor was 5.8 years. Time to up-grading of non-contrast enhanced brain tumor was 16.8 months. Detailed time relations of glioma subgroup will be displayed in tables.

CONCLUSION

Regarding MRI postcontrast non-enhanced tumors, predominantly low grade gliomas (LGG), aggressive oncotherapy are reluctant to use but they are prone to repeat surgeries. Decision making issues are age, clinical patient status, histologic and genetic tumor characteristics, residual tumor volume, published guidelines for brain tumor treatment, and patient′s willing. Generally, hyposignal on the T1 postcontrast scans strictly relate to the better prognosis, even in HGG. Longer survival expectancy increases quality of life awareness. Prior to MRI postcontrast enhanced evolution and up-grading, T2/FLAIR changes have been demonstrated. T2/FLAIR scans considered also main role in LGG follow-up strategy. Individual tailored therapy is principal strategy.

Supported by Ministry of Health of the Czech Republic, grant nr. NV19-04-00281 and grant nr. NU21-03-00195

Analyse des demandes d’appui en matière de prévention et contrôle de l’infection d’un CPias pendant la crise COVID-19

Introduction

Pendant la crise sanitaire liée au SARS-CoV-2, le Centre d’appui pour la Prévention des infections associées aux soins (CPias) a fortement été sollicité par les différents secteurs de l’offre de soins. Un outil informatique commun a été créé en 2019 pour tracer les demandes d’appui du CPias. L’objectif est d’analyser les thèmes abordés, les demandeurs et les réponses émises.

Matériels et méthodes

La saisie de ces données se fait à partir d’un formulaire en ligne. L’analyse des données est réalisée avec le logiciel statistique SAS®. Après un contrôle de la qualité des données, une analyse descriptive des conseils donnés a été réalisée. Ainsi, les variables recensées sont : la date, la fonction des appelants, le statut et le type de leurs établissements (sanitaire, ESMS, secteur libéral…) et les thèmes des demandes. Une fois la base de données exportée et les demandes étiquetées « COVID-19 » filtrées, une seconde analyse qualitative des sous-thèmes a été faite.

Résultats

Entre le 1^er février et le 31 mai 2020, le CPias a répondu à 886 sollicitations sur le thème du COVID-19 contre 640 sur toute l’année 2019 (tous thèmes confondus), avec un pic visible autour de la semaine 12. Ainsi, 64 % (466) des demandes émanent d’établissements médicosociaux, 26 % (189) d’établissements sanitaires, 7 % (48) de tutelles et 3 % (22) de la médecine ambulatoire. Quarante-trois pour cent (363) de ces demandes sont faites par des professionnels de santé (à parts égales entre professionnels médicaux et paramédicaux), 26 % (217) par des personnels non soignants (dont 80 % (174) de directeurs de structures médicosociales), 21 % (175) par des hygiénistes (praticiens et infirmiers) et 10 % (90) d’autres professionnels. Les thèmes les plus souvent abordés concernent pour 30 % (264) les équipements de protection individuelle (conseils pour leur bonne utilisation, gestion de la pénurie), pour 23 % (206) l’environnement (entretien des locaux, gestion du risque environnemental) et pour 21 % (185) la conduite à tenir face à des patients/résidents suspects, positifs ou revenant d’hospitalisation. Viennent ensuite des questions sur la conduite à tenir pour les professionnels soit 14 % (123) (suspects/contact, ceux travaillant en ville ou à domicile) et 14 % (120) sur la maladie elle-même (contagiosité, symptômes, prélèvement, unité dédiée aux patients COVID ou suspects). Parfois ces questions ont été relayées aux infectiologues selon le niveau d’expertise requis. Enfin, 11 % (98) des demandes sont d’ordre organisationnel autour des flux internes et de l’organisation des consultations.

Conclusion

Le CPias a été très investi dans ses missions régionales de prévention et contrôle de l’infection pendant cette crise sanitaire. Nous en tirons que de nombreux acteurs en santé avaient besoin d’une adaptation ou d’une interprétation pratique des doctrines nationales et/ou d’être confortés dans les conduites à tenir. L’analyse montre également la diversité des appelants sortants du cadre habituel de nos interlocuteurs témoignant de l’importance de l’épidémie.

[Paraneoplastic pemphigus: a pustular form during chronic lymphoid leukemia]

BACKGROUND

Paraneoplastic pemphigus is an autoimmune disease of the skin and mucosa described in 1990. The condition is generally associated with lymphoma or chronic lymphoid leukemia. Lesions are often misleading, masquerading as polymorphous erythema or lichen. We report a case of paraneoplastic pemphigus with pustulous skin lesions.

CASE REPORT

A 52-year-old man developed over a few weeks time erosive lesions of the oral cavity and lips associated with papulous skin lesions. Secondarily, large-sized pustules, sometimes a hypopion, were observed associated with bullae. The diagnosis of paraneoplastic pemphigus was confirmed by direct immunofluorescence that evidenced IgG deposits within the keratinocytes and along the basal membrane and by indirect immunofluorescence on rat bladder that evidenced circulating antibodies. This paraneoplastic pemphigus was the inaugural sign of chronic lymphoid leukemia.

DISCUSSION

Skin lesions described in paraneoplastic pemphigus include: erosion, vesicles, bullae, and psoriasiform, lichen-like, plate-like or vegetative formations. To our knowledge, this is the first report of a pustulous form; clinically similar to Hallopeau pustulous pemphigus.

[Chronic desquamative gingivitis syndrome: retrospective analysis of 33 cases]

OBJECTIVE

Desquamative gingivitis is a chronic diffuse inflammation of the gingiva. The aim of this study was to determine the causes and the clinical characteristics of desquamative gingivitis.

PATIENTS AND METHODS

This was a retrospective descriptive study including 33 consecutive patients (25 women and 8 men) seen at a dermatology clinic for erosive gingivitis.

RESULTS

Thirteen patients (39 p. 100) had cicatricial pemphigoid, 12 (36 p. 100) had lichen planus, and 5 (15 p. 100) had pemphigus. Delay to diagnosis was a mean 19 months. The pinch sign was positive in 12 of the 13 cases of cicatricial pemphigoid. Dapsone improved the buccal lesions of cicatricial pemphigoid in all cases. Systemic corticosteroid therapy and acitretine were the most effective treatments for lichen planus and corticosteroid therapy improved pemphigus in all cases. At the time of assessment, only 3 cases of cicatricial pemphigoid, 2 cases of lichen planus and 1 case of pemphigus had reached complete remission without treatment.

DISCUSSION

Cicatricial pemphigoid and lichen planus are the most frequent causes of desquamative gingivitis, accounting for three-quarters of the cases. Positive diagnosis may be difficult and may require sophisticated techniques to avoid delay. Despite the effectiveness of symptomatic treatment, desquamative gingivitis may have a long course.

Hospitalizations due to falls in Jewish and Arab children in northern Israel

In Israel, there are no epidemiological data regarding nonfatal childhood falls. A retrospective survey was conducted in order to find epidemiological characteristics of childhood falls among the different populations of northern Israel. During the years 1993 through 1995, 3082 children were hospitalized in Rambam Medical Center (RMC) due to injury. The children were subdivided into the four main populations: Jewish and Arab residents of Haifa region (the main metropolitan area) and Jewish and Arab residents of the Galilee region (the rural region). All of the children who suffered injury that required mechanical ventilation and careful assessment were admitted to the PICU. The charts of the children admitted to the PICU were then further studied. The demographic characteristics of all the cases of falls were statistically analyzed and the annual admission rates due to falls were calculated using the national statistical registrations of children in Israel. Falls were responsible for 1049 admissions due to injury, one third of the total number of children who were admitted due to an injury. Most of the children were five years of age or younger. Two thirds of the total childhood falls were of Arabs. The majority of the admissions were of two major sub-populations of northern Israel: Arab residents of Galilee region (66%) and Jewish residents of Haifa region (34%). Higher admission rate was found among Arab children of the Western Galilee district in comparison with Jewish children of the Haifa district. Most of the children who were admitted to the PICU were Arabs: nearly all of these children were from the rural region. More Arab than Jewish children who fell were admitted to the PICU and the majority of these cases were falls from buildings (private houses). Arab children of the rural region were responsible for 95% of the cases. These falls were mainly in staircases (46%) and from balconies (21%), roofs (11%) and windows (11%). The findings of the present study suggest that young Arab rural children in northern Israel are at high risk to a severe injury due to fall. Possible causes are discussed and a preventative intervention is suggested.

[Granuloma faciale: efficacy of cryosurgery in 2 cases]

BACKGROUND

Granuloma faciale is a rare condition of unknown pathogenesis. Treatment often gives less than satisfactory results. We report two cases successfully treated with cryosurgery.

CASE REPORT

A 42-year-old woman had a round 65 x 40 mm erythematous violet-colored papulous plaque on the right cheek. Histology reported a dense inflammatory infiltration of the superficial and mid derma around dilated vessels under a normal epidermis. The infiltration was composed of histiocytes, lymphocytes, plasma cells, neutrophils and eosinophils and was compatible with granuloma facial. Surgical treatment was performed but was followed by recurrence within a few months. Class I local steroids, cotton swab cryotherapy and oral dapsone remained ineffective. Cryosurgery however led to cure without recurrence at 1 year follow-up. The second patient was a 52-year old man with an oval reddish-brown papulous plaque on the right preauricular area. The plaque measured 40 mm in diameter and histology favored granuloma facial. Three cotton swab cryotherapy sessions and one surgical excision procedure were followed by recurrence. Cryosurgery provided successful cure without recurrence at 3.5 years follow-up.

DISCUSSION

Most destructive treatments for granuloma facial, including pulverization cryotherapy, surgery, and CO(2) or argon laser are unsuccessful in preventing recurrence. Cryosurgery was proposed in 1977 but few cases have been reported since. Medical treatments have been variously successful with most authors reporting unsatisfactory results. In our two cases, surgical excision was rapidly followed by recurrence and in one case dapsone was ineffective. Cryosurgery provided rapid regression of the lesion and recurrence-free cure at 1 and 3.5 years follow-up respectively. Cryosurgery is an effective treatment for readily recurrent eosinophilic granuloma facial and should be proposed as first intention therapy.

Short-term cyclosporin monotherapy for chronic severe plaque-type psoriasis

Cyclosporin is an effective treatment for psoriasis but its efficacy is only palliative. The aim of this study was to evaluate the percentage of patients in whom a short term therapy may be used without relapse after discontinuation of cyclosporin. In this multicenter, open, non-controlled study fifty-eight patients were included who had severe and extensive chronic plaque-type psoriasis. Treatment duration was 28 weeks. The absence of relapse was defined as the requirement to resume systemic treatment at 16 weeks after discontinuation of Sandimmun . The overall efficacy of Sandimmun at W20 was 72%. No relapse or premature withdrawal occurred in 18 cases out of 39 (47%). In these cases local treatment was sufficient following discontinuation. Thus we show the potential value of a single 5 month course of cyclosporin treatment. In this study tapering of cyclosporin was not useful. In 50% of cases short-term cyclosporin treatment was not followed by resumption of systemic treatment and constitutes an improvement in qualify of life.

Immune response in acute coronary syndromes

Inflammatory response in the atherosclerotic lesions of coronary artery disease, mediated by cellular immune mechanisms is well appreciated. The significance of the immuno-inflammatory processes for the development of acute ischaemic sequelae of these lesions remains unsettled. Fifty patients of acute coronary syndromes were studied for complement components and immunoglobin levels by single radial immunodiffusion method. Twenty-eight patients of acute myocardial infarction showed significantly lower levels of complement components C3 and C4 at admission (C3--69.19 +/- 12.91 mg% compared to 82.40 +/- 9.26 mg% in controls, p < 0.01; C4--14.56 +/- 2.46 mg% compared to 18.53 +/- 2.69 mg% in controls, p < 0.01). Twenty-two patients of unstable angina did not show any significant change (C3--83.14 +/- 8.01 mg% and C4--19.07 +/- 4.47 mg%). Sixteen patients of acute myocardial infarction who were thrombolysed with streptokinase showed a steep rise in the levels of complement components immediately after thrombolysis (C3--69.19 +/- 12.91 mg% before and 100.56 +/- 17.09 mg% after thrombolysis, p < 0.001; C4--14.56 +/- 2.46 mg% before and 21.48 +/- 4.78 mg% after thrombolysis, p < 0.001). Plasma C3 and C4 levels in acute myocardial infarction showed no relationship with peak CPK levels. Plasma immunoglobulins remained unchanged in patients of acute coronary syndromes.

[D-penicillamine-induced pemphigus, polymyositis and myasthenia]

BACKGROUND

D-penicillamine can induce autoimmune disease, particularly in patients with associated immune disorders.

CASE REPORT

A 67-year old woman who had been taking D-penicillamine for 15 months for rheumatoid arthritis was hospitalized due to the development of a bullous eruption and proximal muscle deficiency. Search for intercellular antisubstance antibodies in serum was negative. The skin biopsy histology revealed intra-epidermal cleavage in the mucosal body and direct immunofluorescence revealed epidermal frame-marking with anti-IgG and anti-C3 antibodies. Other tests revealed muscular cytolysis, and anti-acetylcholine receptor antibodies. The electromyogram showed neuromuscular block without muscle deficiency and muscle biopsy showed moderate myositis. D-penicillamine was interrupted and was followed by cure of the pemphigus and aggravation of the myositis, requiring high-dose systemic corticosteroid therapy.

DISCUSSION

This patient developed D-penicillamine induced pemphigus, a rather frequent observation. The desmoglein immunolabelling favored drug-induced pemphigus and the course was rapidly favorable after withdrawal. Pemphigus had developed simultaneously with signs of myasthenia and polymyositis. Polymyositis and myasthenia are also known complications of D-penicillamine therapy. The association of these three complications suggests that D-penicillamine can unmask certain antigens or have an immunomodulator effect.

[Chronic radiodermatitis after heart catheterization: the contributing role of ciprofibrate (Lipanor)?]

BACKGROUND

Radiodermatitis after cardiac catheterization procedures has been reported in only a few cases in the literature. This side effect may not however be uncommon after long or repeated endocavitary explorations.

CASE REPORT

We observed a case of chronic radiodermatitis which developed after cardiac catheterization, in a patient treated with corticosteroids and ciprofibrate for lupus. The patient had undergone only one heart catheterization. A second catheterization performed when the patient had stopped ciprofibrate did not provoke new lesions.

DISCUSSION

This observations would suggest that ciprofibrate could participate as a radiosensitizing factor in the development of radiodermatitis.

Clinical spectrum of infective endocarditis: 15 years experience

Four hundred and sixty-six patients (277 males, 189 females; mean age 23.2 years) diagnosed as cases of infective endocarditis during the past 15 years were retrospectively analysed. Two-thirds of patients belonged to the 15 to 35 years age group. The most common predisposing cardiac lesion was rheumatic heart disease seen in 73.4 percent patients. Mitral valve prolapse and right-sided endocarditis were infrequent, seen in four patients each. Blood culture positivity was 28.7 percent in adults and 61 percent in children. Commonest organism isolated was staphylococcus aureus in adults (39.3%) and streptococcus viridans in children (48%). Salmonella typhi was detected in 17 patients and showed excellent response to ciprofloxacin and gentamycin. Overall mortality was 13.9 percent and resistant heart failure was the leading cause of death. Our study presents the clinical spectrum of infective endocarditis and highlights the comparison with western studies.

[Hepatic artery ligation for liver metastasis of a acinar cell carcinoma of the pancreas revealed by a nodular panniculitis]

We report the case of a 67-year-old-man presenting with pancreatic acinar cell carcinoma revealed by dermatological manifestations of cytosteatonecrosis and treated by hepatic artery ligation. The pancreatic etiology of these lesions was suspected due to hyperlipasemia, and was confirmed by abdominal computerized tomography showing a pancreatic tumor and multiple liver nodules, and by histological examination of one of these lesions. Because of symptomatic treatment failure, rapid impairment of patient's general condition, and by analogy with the treatment of hepatic metastases of neuroendocrine tumors, hepatic artery ligation was performed. Lipasemia decreased markedly and symptoms disappeared for 45 days. Hepatic artery obstruction may be used for emergency treatment of secreting liver metastases.

CYFRA 21-1 is not superior to SCC antigen and CEA in head and neck squamous cell cancer

CYFRA 21-1 was compared to the most reliable tumor markers for squamous cell carcinoma of the head and neck (HNSCC), SCC antigen and CEA. Sera of 163 patients with primary and 40 patients with recurrent HNSCC were examined. 94 patients with non-malignant ENT-diseases served as the control group. To give a specificity of 95% the cut-off-values were as follows: SCC: 1.9 ng/ml, CEA: 3.8 ng/ml, CYFRA 21-1: 2.9 ng/ml. SCC had the highest sensitivity at the time of primary diagnosis (P) at 43% and 61% at relapse (R), compared to CEA with P: 35%, R: 40% and CYFRA 21-1 with P: 17%, R: 18%. We show that CYFRA 21-1 cannot offer additional information to the clinical outcome of patients with HNSCC, whereas combined analysis of SCC and CEA leads to a markedly increased sensitivity of 60% at primary diagnosis and of 79% in cases of tumor relapse.

Cutaneous alternariosis: role of corticosteroid-induced cutaneous fragility

Alternaria is a very common and saprophytic fungus. Cutaneous infection is rare and about 71 cases have been described, mainly in Europe in immunocompromised hosts. We report a case of dermal alternariosis occurring in a woman treated with corticosteroids for dermatomyositis. The cutaneous lesion consisted of an erythematous and scaly plaque on the leg measuring 2 x 2 cm. Cutaneous biopsy showed hyphae and round inclusions stained with PAS and Gomori-Grocott within a polymorphous granuloma. Cultures of cutaneous biopsies grew Alternaria sp. HIV1 and HIV2 serology was negative. The patient was treated by local excision and corticosteroids were decreased. One-year follow-up showed no recurrence. Cutaneous alternariosis is an opportunistic infection. the disease has been described mainly in patients treated with systemic corticosteroids (39 cases out of the 71 reported cases) or local corticosteroids (3/71) and in patients suffering from Cushing's syndrome (7/71) but rarely in HIV-infected patients (3/71). Cutaneous fragility induced by hypercorticism is an important cofactor permitting direct inoculation from the environment.