Acute bacterial prostatitis: heterogeneity in diagnostic criteria and management. Retrospective multicentric analysis of 371 patients diagnosed with acute prostatitis

BACKGROUND

There is currently a lack of consensus for the diagnosis, investigations and treatments of acute bacterial prostatitis (AP).

METHODS

The symptoms, investigations and treatments of 371 inpatients diagnosed with AP were analyzed through a retrospective study conducted in four departments - Urology (U), Infectious Diseases (ID), Internal Medicine (IM), Geriatrics (G) - of two French university hospitals.

RESULTS

The cause of admission, symptoms, investigations and treatments depended markedly on the department of admission but not on the hospital. In U, patients commonly presented with a bladder outlet obstruction, they had a large imaging and functional check-up, and received alpha-blockers and anti-inflammatory drugs. In ID, patients were febrile and received longer and more appropriate antibiotic treatments. In G, patients presented with cognitive disorders and commonly had post-void urine volume measurements. In IM, patients presented with a wide range of symptoms, and had very diverse investigations and antibiotic regimen.Overall, a 3:1 ratio of community-acquired AP (CA-AP) to nosocomial AP (N-AP) was observed. Urine culture isolated mainly E. coli (58% of AP, 68% of CA-AP), with venereal agents constituting less than 1%. The probabilistic antibiotic treatments were similar for N-AP and CA-AP (58% bi-therapy; 63% fluoroquinolone-based regimen). For N-AP, these treatments were more likely to be inadequate (42% vs. 8%, p < 0.001) and had a higher rate of bacteriological failure (48% vs. 19%, p < 0.001). Clinical failure at follow-up was more common than bacteriological failure (75% versus 24%, p < 0.001). Patients older than 49 had more underlying urinary tract disorders and a higher rate of clinical failure (30% versus 10%, p < 0.0001).

CONCLUSION

This study highlights the difficulties encountered on a daily basis by the physicians regarding the diagnosis and management of acute prostatitis.

Pneumopathie avec bactériémie à Yersinia enterocolitica chez un patient diabétique porteur de l'antigène HLA-B27

INTRODUCTION

We report a new case of pneumonia and bacteremia due to Yersinia enterocolitica (YE) in a diabetic patient with HLA-B27 positive spondylarthritis.

OBSERVATION

A 75-year-old man was admitted for a pneumonia. He was suffering from HLA-B27 positive spondylarthritis and stable diabetes mellitus. Amoxicillin with clavulanic acid was ineffective. Two blood and stool cultures were positive for YE. There was no evidence of septic metastases, immunodepression and iron overload. Outcome was uneventful after 21 days of ofloxacin.

CONCLUSION

YE pneumonia is rare. In this patient, diabetes mellitus and spondylarthritis with HLA-B27 may have played a role in the infection but their imputability remain questionable.

Anticardiolipin and anti-beta2 glycoprotein I antibodies and lupus-like anticoagulant: prevalence and significance in systemic sclerosis

BACKGROUND

It has been suggested that both anticardiolipin (aCL) and anti-beta(2) glycoprotein I (abeta(2)GPI) antibodies may play a critical role in the pathogenesis of systemic sclerosis (SSc)-related vascular impairment.

OBJECTIVES

To evaluate the prevalence of aCL and abeta(2)GPI antibodies and lupus-like anticoagulant (LAC) in patients with SSc and healthy controls. We also investigated a possible relationship between clinical and biological variables of patients with SSc and the presence of aCL/abeta(2)GPI antibodies and/or LAC.

METHODS

Measurements of aCL and abeta(2)GPI antibodies, and LAC were performed in 69 consecutive patients with SSc and 69 age- and sex-matched controls. Clinical and biological findings were compared between patients with and without antiphospholipid antibodies.

RESULTS

aCL and abeta(2)GPI antibodies and/or LAC were detected in 13 (19%) of 69 consecutive patients with SSc; in the healthy control group, aCL antibody was found in only one (2%) subject (P = 0.0007). None of the healthy controls had abeta(2)GPI antibody and/or LAC. Moreover, pitting scars, pulmonary arterial hypertension, macrovascular involvement as well as severity of capillary impairment (using nailfold videocapillaroscopy) were more frequent in SSc patients with aCL/abeta(2)GPI antibodies and/or LAC compared with those without.

CONCLUSIONS

Our findings suggest that antiphospholipid antibodies may have a role in the genesis of vascular involvement related to SSc. Finally, the assessment of antiphospholipid antibodies (aCL and abeta(2)GPI antibodies, as well as LAC) may contribute to a better recognition of clinical features in patients with SSc; in essence, the patients with aCL/abeta(2)GPI antibodies and/or LAC may require close monitoring of vascular changes, including in particular pulmonary arterial hypertension and digital infarcts.

Plasma D-dimer concentration in patients with systemic sclerosis

BACKGROUND

It has been reported that increased plasma D-dimer is a reliable marker of systemic prothrombotic state in patients with cardiovascular diseases.

OBJECTIVES

To evaluate plasma D-dimer concentration in patients with systemic sclerosis (SSc) and healthy controls. We also investigated a possible relationship between the presence of a high plasma D-dimer concentration and clinical and biological parameters in patients with SSc.

METHODS

Measurements of plasma D-dimer concentration were performed in 69 consecutive patients with SSc and 69 age- and sex-matched controls. Clinical and biological findings were compared between patients with and without a high concentration of plasma D-dimer (i.e. >or=500 ng mL(-1)).

RESULTS

Median plasma D-dimer concentrations appeared significantly increased in patients with SSc compared with control subjects (506 vs. 211 ng mL(-1); P<0.001). Furthermore, a high concentration of plasma D-dimer (>or=500 ng mL(-1)) was detected more frequently in patients with SSc than in healthy controls (47.8% vs. 4.5%; P<0.0001). Among vascular manifestations related to SSc, macrovascular impairment responsible for peripheral ischaemia was more frequent in patients with SSc with high levels of D-dimer (>or=500 ng mL(-1)), compared with those without (21% vs. 6%; P=0.05).

CONCLUSIONS

The association between high levels of plasma D-dimer (>or=500 ng mL(-1)) and macrovascular involvement in patients with SSc is likely to be an innovative issue. We suggest that D-dimer levels may be a helpful additional test to identify patients with SSc at risk to develop thrombotic arterial complications (peripheral arterial disease, stroke and coronary event); such patients with high levels of plasma D-dimer (>or=500 ng mL(-1)) may require close monitoring of vascular parameters, including especially macrovascular impairment.

Long-term follow-up of hypothenar hammer syndrome: a series of 47 patients

Hypothenar hammer syndrome (HHS) is an uncommon form of secondary Raynaud phenomenon, occurring mainly in subjects who use the hypothenar part of the hand as a hammer; the hook of the hamate strikes the superficial palmar branch of the ulnar artery in the Guyon space, leading to occlusion and/or aneurysm of the ulnar artery. In patients with HHS, such injuries of the palmar ulnar artery may lead to severe vascular insufficiency in the hand with occlusion of digital artery. To date, only a few series have analyzed the long-term outcome of patients with HHS. This prompted us to conduct the current retrospective study to 1) evaluate the prevalence of HHS in patients with Raynaud phenomenon and 2) assess the short-term and long-term outcome in patients with HHS. From 1990 to 2006, 4148 consecutive patients were referred to the Department of Internal Medicine at the University of Rouen medical center for evaluation of Raynaud phenomenon using nailfold capillaroscopy. HHS was diagnosed in 47 of these 4148 patients (1.13% of cases).Forty-three patients (91.5%) had occupational exposure to repetitive palmar trauma. The more common occupations were factory worker (21.3%), mason (12.8%), carpenter (10.6%), and metal worker (10.6%); the mean duration of occupational exposure to repetitive palmar trauma at HHS diagnosis was 21 years. One patient (2.1%) had recreational exposure (aikido training) to repetitive trauma of the palmar ulnar artery, and 3 other patients (6.4%) developed HHS related to a single direct injury to the hypothenar area. Clinical manifestations were more often unilateral (87.2%) involving the dominant hand (93%). HHS complications included digital ischemic symptoms (ischemia: n = 21, necrosis: n = 20) and irritation of the sensory branch of the ulnar nerve (n = 11). In HHS patients, angiography demonstrated occlusion of the ulnar artery in the area of the Guyon space (59.6%), aneurysm of the ulnar artery in the area of the Guyon space (40.4%), and embolic multiple occlusions of the digital arteries (57.4%). All patients were advised to change their occupational exposure. They were given vasodilators, including calcium channel blocker (n = 37) and buflomedil (n = 12); 36 patients (76.6%) also received oral platelet aggregation inhibitors. Twenty-one patients with digital ischemia/necrosis were further given hemodilution therapy to reduce the hematocrit level to 35%. In 3 patients with HHS-related digital necrosis who exhibited partial improvement with vasodilators, prostacyclin analog therapy (a 5-day regimen of intravenous prostacyclin analog) was instituted, resulting in complete healing of digital ulcer in these 3 patients. Other conservative treatment options included controlling risk factors (smoking cessation, low-lipid diet, therapy for arterial hypertension) and careful local wound care of fingers in the 20 patients with digital necrosis. Only 2 patients, exhibiting digital necrosis and multiple digital artery occlusions, with nonthrombotic ulnar artery aneurysm underwent reconstructive surgery, that is, resection of the aneurysm with end-to-end anastomosis of the ulnar artery. The median length of follow-up in patients with HHS was 15.9 months. Thirteen patients (27.7%) exhibited clinical recurrences of HHS; the median time of HHS recurrence onset was 11 months. Outcome of HHS relapse was favorable with conservative measures in all cases. Awareness of HHS is required to increase suspicion of the disorder so that further exposure to risk factors like repetitive hypothenar trauma can be avoided for these patients; this is of great importance for their overall prognosis. We found favorable outcomes in most patients after conservative measures were initiated; therefore we suggest that surgery may be undertaken in the subgroup of patients who exhibit partial improvement while receiving conservative therapy. Finally, because we observed recurrence of HHS in 27.7% of patients, we note that HHS patients require close follow-up, including both regular and systematic physical vascular examination.

[Typhlitis: report of a case and review of the literature]

INTRODUCTION

Typhlitis is a rare condition, characterized by necrotizing inflammation of the colon. It occurs mainly in neutropenic patients receiving chemotherapy for leukemia.

EXEGESIS

We report the case of a 64-year-old woman with T-cell lymphocytic leukaemia, who exhibited asymptomatic reactivation of cytomegalovirus infection and developed subsequently typhlitis.

CONCLUSION

The pathological mechanisms of typhlitis remain unclear in neutropenic patients. The role of cytotoxic drugs as well as both bacterial overgrowth and translocation has been postulated. In our patient, asymptomatic reactivation of cytomegalovirus infection may have increased chemotherapeutic-agents-digestive toxicity.

[Liver involvement in hereditary haemorrhagic telangiectasia (Rendu-Osler-Weber disease). Report of one case and review of the literature]

INTRODUCTION

Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant vascular dysplasia; mutations in at least three genes (ENG, ACVRL1 et MADH4), which are components of transforming growth factor (TGF)-beta, may lead to the clinical picture of HHT. HHT is a multisystemic angiodysplasia, resulting in multiple vascular malformations, involving notably the liver.

EXEGESIS

We report the case of a patient with anicteric cholestasis, revealing HHT. Abdominal CT-scan revealed hepatic artery dilation and multiple arteriovenous fistula. At 2-year follow-up, the patient exhibited liver involvement-associated high output cardiac insufficiency.

CONCLUSION

Liver involvement is frequent in HHT, occurring in 8-31% of patients; it may lead to life-threatening complications, such as high output cardiac failure, portal hypertension or severe cholangitis. Abdominal Doppler ultrasonography is a non-invasive accurate method, suitable for first-line imaging of the liver in patients with HHT; it should be done in all patients, in order to detect HHT-related hepatic vascular malformations.

Typhlitis as a complication of alemtuzumab therapy

Alemtuzumab is a humanized monoclonal antibody directed against lymphocytes through the CD-52 receptor, an antigen being found on > 95% of peripheral blood lymphocytes and monocytes, and to a smaller extent on granulocytes. It is an effective immunotherapeutic agent in patients with malignancies such as non-Hodgkin lymphoma, B cell chronic lymphocytic leukemia and T cell pro- lymphocytic leukemia. Adverse side effects are increasingly recognized in patients receiving alemtuzumab, mainly including fever, rigors, nausea/vomiting, skin rash; other severe alemtuzumab-related reactions have also been described, such as lymphopenia and neutropenia leading to both opportunistic (e.g. cytomegalovirus) and non-opportunistic infections. Digestive complications have more rarely been described, i.e.: gastroenteritis and peritonitis. We recently observed a case of particular interest as the patient with T cell prolymphocytic leukaemia treated with alemtuzumab, exhibited symptomatic reactivation of CMV infection and developed subsequently typhlitis.

Oesophageal mucosal involvement in patients with systemic sclerosis receiving proton pump inhibitor therapy

AIM

To assess the prevalence of oesophagitis, Barrett's oesophagus (BE) and other oesophageal mucosal abnormalities in patients with systemic sclerosis (SSc) without prior selection on digestive clinical presentation. We also investigated the association between oesophageal endoscopic and manometric data with clinical manifestations of SSc.

METHODS

Oesophageal endoscopy and manometry were performed in 133 consecutive patients with SSc, receiving proton pump inhibitor (PPI) therapy since SSc diagnosis.

RESULTS

Endoscopy revealed oesophagitis in 43 patients (32.3%), BE in 9 patients (6.8%), candidiasis in 7 patients (5.3%) and hyperplastic polyp arising in ectopic gastric mucosa in 1 patient. Patients with severe oesophageal motor impairment further exhibited a higher prevalence of interstitial lung disease (ILD) when compared with those without.

CONCLUSION

Our study underlines the high frequency of oesophageal mucosal abnormalities in unselected SSc patients receiving long-term PPI therapy. A relationship between oesophagitis/BE and severe manometric motor disturbances was established; these patients may require a higher regimen of PPI. Finally, our series indicates a correlation between severe oesophageal motor disturbances and evidence for ILD in patients, suggesting that gastro-oesophageal reflux may be one of the contributing factors of ILD in SSc; this subgroup of patients may require close monitoring of lung parameters.

Intravenous immunoglobulin-associated cranial pachymeningitis

To date, intravenous immunoglobulin (IvIg) has more often been considered as a safe medication. However, with the wider use of IvIg, severe side effects have also been reported to occur in IvIg-treated patients, notably aseptic meningitis. Other neurological complications have more rarely been described in patients receiving IvIg therapy, e.g. stroke or acute encephalopathy. We recently observed a case which is of particular interest, as the patient with steroid-refractory polyarteritis nodosa developed cranial pachymeningitis related to IvIg therapy. To our knowledge, this is the first reported case of cranial pachymeningitis complicating IvIg therapy. Our findings emphasize the importance of recognizing IvIg-related neurological complications in IvIg-treated patients. As cranial pachymeningitis is a fibrosing process, both recognition and management at an early stage are required to prevent definite neurological impairment in patients.

Leishmaniose cutanée au cours d'une polymyosite

INTRODUCTION

The prevalence of cutaneous leishmaniasis is increasing, especially in immunocompromized subjects.

CASE RECORD

We report a case of particular interest, where a patient with steroid refractory polymyositis developed cutaneous leishmaniasis. Clinical outcome was favorable after institution of intralesional antimony therapy.

DISCUSSION

Cutaneous leishmaniasis is still recognized to be an opportunistic infection. Its frequency is indeed higher in immunocompromized subjects, mainly HIV-infected patients. In our patient, both polymyositis and steroid therapy were predisposing factors of cutaneous leishmaniasis onset; prednisone therapy has been postulated to be associated with immune dysfunction leading to: reduced blood T cells' levels (CD4 et CD8) as well as decreased cytokine synthesis (e.g. interferon gamma).

Intravenous immunoglobulin-associated arterial and venous thrombosis; report of a series and review of the literature

BACKGROUND

To date, the prevalence of intravenous immunoglobulin (IvIg)-related thrombotic complications has not been evaluated in patients with autoimmune disorders followed up in Departments of Internal Medicine.

OBJECTIVES

To assess prevalence and characteristics of IvIg-related thrombotic complications in patients with autoimmune disorders receiving IvIg therapy; to evaluate the predictive factors for onset of IvIg-related thrombotic manifestation in patients, and to detect patients at risk for these types of complications.

PATIENTS AND METHODS

The medical records of 46 patients with autoimmune disorders who were given IvIg therapy at our Department of Internal Medicine between January 2002 and December 2004 were reviewed.

RESULTS

Among the 46 patients, nine exhibited IvIg-associated severe complications (19.6%). Six patients (13%) developed IvIg-related thrombotic complications. Thrombotic complications frequently occurred during IvIg infusion (50%), although they were also observed within 1-8 days following IvIg infusion in other patients. IvIg-related thrombotic complications consisted of: deep venous thrombosis or pulmonary embolism (n = 3), myocardial infarction (n = 2) and stroke (n = 1). The outcome of thrombotic complications was favourable in all patients, after appropriate therapy institution. Older age, history of associated arterial hypertension and hypercholesterolaemia were more common in the group of patients with IvIg-related thrombotic complications.

CONCLUSIONS

Our study demonstrates that IvIg-related thrombotic arterial/venous complications are not uncommon in patients with autoimmune disorders (13% of patients). Nevertheless, patients, who are followed up in Departments of Internal Medicine often have concomitant disorders placing them at increased risk to develop IvIg-related thrombotic complications; the latter may also explain the high rate of IvIg-related thrombosis in our cohort. Our series further indicates that patients should be monitored closely for these types of adverse events during the whole period of IvIg therapy, as thrombotic manifestations occurred in patients who had received multiple IvIg infusions without exhibiting complications. In addition, our results suggest that it is questionable to initiate IvIg therapy in patients presenting with predictive factors of thrombotic complications; in this subgroup of patients, IvIg should be prescribed cautiously, after re-weighing risk-benefit considerations.

Outcome of small-bowel motor impairment in systemic sclerosis--a prospective manometric 5-yr follow-up

OBJECTIVE

To assess the 5-yr course of small-bowel motor disorders, using manometry in patients with systemic sclerosis (SSc), and to investigate for an association between small-bowel motor dysfunction outcome and other clinical manifestations of SSc.

METHODS

Fasting and post-prandial motor activity of the small-bowel was systematically assessed in eight consecutive patients with SSc, using 24 h manometry: initially and at 5-yr follow-up.

RESULTS

At 5-yr follow-up, the eight SSc patients (100%) exhibited deterioration of small-bowel motor activity on manometry as follows: (1) more severe abnormalities of migrating motor complex phase III during the fasting period; (2) decreased median duodenal and duodeno-jejunal index during the post-prandial period; and (3) more frequent alterations of small-bowel motor activity in response to octreotide infusion. Furthermore, an association could be found between the deterioration of small-bowel motor function and pitting scars' onset.

CONCLUSION

Our study underscores the rapid deterioration of small-bowel motor impairment in SSc patients (100%). It also highlights the usefulness of small-bowel manometry in symptomatic SSc patients in objectively defining both the characteristics and degree of motor impairment, which may influence the choice of medical treatment in patients, particularly octreotide therapy.

Helicobacter heilmanii gastritis in polymyositis

We report the original case of a patient with polymyositis (PM) who developed severe gastritis related to Helicobacter heilmanii. H. heilmanii eradication, using triple therapy with omeprazole, metronidazole and amoxicillin, resulted in the complete disappearance of digestive manifestations. As an association has been found between gastric adenocarcinoma/MALT lymphoma and both polymyositis/dermatomyositis (PM/DM) and H. heilmanii infection, respectively, we suspect that PM/DM patients who develop H. heilmanii infection may have a higher risk of gastric malignancy occurrence. Further studies are warranted to confirm whether Helicobacter species infections do, in fact, increase the risk of gastric adenocarcinoma/MALT lymphoma in patients with PM/DM.

Dermatose neutrophilique, au décours d’une lymphadénopathie angio-immunoblastique, avec dysmyélopoïèse induite par le cyclophosphamide

BACKGROUND

Cutaneous involvement in patients with angioimmunoblastic lymphadenopathy is often poorly specific for maculopapular eruptions. We report an atypical case of neutrophilic disorder associating subcorneal pustules and hypodermal nodules in a male patient with angioimmunoblastic lymphadenopathy.

CASE REPORT

A 62 year-old man with angioimmunoblastic lymphadenopathy was treated with oral prednisone (15 mg/day) and cyclophosphamide. Pustules and deep nodules occurred simultaneously on the arms and trunk, the abdomen and the back respectively. Biopsy of these lesions showed an infiltration of neutrophil polymorphonuclears in the median and superficial dermis with a subcorneal pustule and nodular infiltration of neutrophil polymorphonuclears in the deep dermis and hypodermis respectively. Increasing the dose of prednisone to 30 mg/day led to rapid and complete healing of the cutaneous lesions.

DISCUSSION

This atypical case of neutrophilic disorder associating acute subcorneal pustules and deep dermal-hypodermal nodules seems to correspond to a unique type of neutrophilic disorder that differs from those previously reported in the literature. Neutrophilic disorders have been reported only rarely in patients with angioimmunoblastic lymphadenopathy. This case illustrates the wide range of clinical and histological lesions found in neutrophilic disorders, a number of which may coexist in a single patient.

Ascites as the first manifestation of polyarteritis nodosa

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that affects numerous organs, particularly the digestive tract (33-52% of cases). However, isolated ascites has rarely been described in patients with PAN. We observed a patient who had developed ascites revealing PAN, and because of suspected malignancy laparotomy and abdominal surgery were performed, including systematic total abdominal hysterectomy, bilateral salpingo-oophrectomy, submesocolic omontectomy and appendicectomy. Macroscopic examination revealed a nodule involving the left ovary, while histological examination of biopsy specimens demonstrated characteristic damage of necrotizing vasculitis involving the appendix, omentum, uterus, fallopian tubes and right ovary, consistent with PAN. The patient had a favourable outcome of clinical manifestations related to PAN after initiation of combined therapy of prednisone and cyclophosphamide. Our case report therefore reinforces the possibility of an unusual presentation of PAN. As ascites may precede other signs of PAN, we suggest that when unexplained ascites is noted an evaluation for misdiagnosed vasculitis should be carried out, including a search of the constitutional symptoms (e.g. fever, weight loss). Patients undergoing laparoscopy for peritoneal involvement of unknown origin should also have tissue specimens taken for pathologic studies, notably to exclude an underlying vasculitis.

Aortite inflammatoire et maladie de Horton. À propos du suivi évolutif scanographique prospectif d'une série de 11 patients

PURPOSE

To determine clinical and radiological features, using computed tomography (CT-scan) in patients with aortic involvement related to giant cell arteritis (GCA), and to assess both clinical and CT-scan outcome after therapy institution.

METHODS

Aortic involvement due to GCA was investigated in all patients, using CT-scan at diagnosis, and at 3, 6 and 12 months follow-up after therapy institution.

RESULTS

The 11 consecutive patients consisted of 4 men and 7 women with mean age of 64.5 years. Patients exhibited: constitutional symptoms (N=9; 82%), dorsalgia (N=3; 27%), clinical signs of GCA (N=3; 27%) and of upper limb large vessel impairment (N=6; 55%). CT-scan showed aortitis involving both thoracic and abdominal aorta (N=6; 55%), abdominal (N=2; 18%) or thoracic aorta (N=2; 18%) and thoracic aortic aneurysm (N=1; 9%). At one-year follow-up, CT-scan revealed: complete resolution (N=7; 64%) and improvement (N=3; 27%) of aortic damage; the patient, who had thoracic aortic aneurysm, underwent surgical treatment, as aortic lesion remained unchanged on CT-scan.

CONCLUSION

Our study underlines that CT-scan is a helpful test in diagnosis and follow-up of aortic involvement in patients with GCA.

[Association of sarcoidosis and Takayasu's arteritis: an additional case report]

INTRODUCTION

Takayasu arteritis has been described in association with various auto-immune disorders (mainly inflammatory digestive tract diseases). However, only few cases of Takayasu arteritis associated with sarcoidosis have been reported, raising the question of an association by chance.

EXEGESIS

We report the case of a 26-year old woman with a 1-year history of sarcoidosis, who presented with a right painful upper limb, revealing inflammatory humeral, axillary and subclavian arteritis related to Takayasu arteritis. The patient was successfully treated with steroids.

CONCLUSION

Our case report suggests that both Takayasu arteritis and sarcoidosis may be related, and that Takayasu arteritis or Takayasu arteritis-like granulomatous vasculitis may be, in fact, a complication of sarcoidosis. It also indicates that a complete vascular clinical examination should be performed in patients with sarcoidosis, in order to detect asymptomatic underlying inflammatory arteritis.

Inflammatory pseudotumor of the liver revealing gynecological Corynebacterium infection

Inflammatory pseudotumor (IPL) of the liver is a rare benign clinicopathologic entity, which has been associated with infectious conditions, including alimentary, digestive tract and mouth infections. We report a new case, where a patient developed hepatic IPL that revealed endometritis related to Corynebacterium infection; the patient had a favorable outcome of hepatic IPL after appropriate antibiotic therapy initiation. Our findings therefore confirm that antibiotic therapy may be effective in patients with hepatic IPL associated with underlying infections, avoiding unnecessary surgery. Our data also indicate that when hepatic IPL is observed, a complete clinical evaluation, including gynecological evaluation, should be systematically performed.

Opportunistic infections in polymyositis and dermatomyositis

OBJECTIVE

To assess prevalence and characteristics of opportunistic infections in patients with polymyositis/dermatomyositis (PM/DM). To determine the predictive values for opportunistic infections on clinical presentation, biochemical findings, and paraclinical features of PM/DM to detect patients at risk of opportunistic infections.

METHODS

The medical records of 156 consecutive PM/DM patients in 3 medical centers were reviewed.

RESULTS

Eighteen PM/DM patients (11.5%) developed opportunistic infections. The majority of patients exhibited an opportunistic infection after the onset of PM/DM (89% of cases). Opportunistic infections occurred most frequently during the first year following PM/DM diagnosis (62.5%). The pathogen microorganisms responsible for opportunistic infections were various, i.e., Candida albicans, Pneumocystis carinii, Aspergillus fumigatus, Geotrichum capitatum, Mycobacterium avium-intracellulare complex, M. xenopi, M. marinum, M. tuberculosis, Helicobacter heilmanii, cytomegalovirus, and herpes simplex virus. Mortality rates were as high as 27.7% in these PM/DM patients. Higher mean daily doses of steroids, lymphopenia, and lower serum total protein levels were significantly more frequent in the group of PM/DM patients with opportunistic infections.

CONCLUSION

Our study underscores the high frequency of opportunistic infections in PM/DM, resulting in an increased mortality rate. It also indicates that a great variety of microorganisms are responsible for opportunistic infections, although they were more often due to fungi (>50% of cases). Our series highlights a predominance of both lung and digestive opportunistic infections (89% of cases). In addition, our results suggest that PM/DM patients presenting with factors predictive of opportunistic infection may require closer monitoring.

Clonal T Cells in the Blood of Patients With Systemic Sclerosis

BACKGROUND

It has been suggested that clonal T cells may play a critical role in the pathogenesis of systemic sclerosis.

OBSERVATIONS

A monoclonal population of T cells was found in blood samples from 13 (34%) of 38 consecutive patients with a definite diagnosis of systemic sclerosis who were prospectively examined by T-cell receptor gamma gene rearrangement using polymerase chain reaction analysis and denaturating gradient gel electrophoresis. In the healthy control group, the same type of examination revealed a monoclonal population of T cells in the blood samples from only 3 healthy subjects (4%)(odds ratio, 12.28; 95% confidence interval, 2.76-54.64; P = .001). Patients who had a circulating clonal population of T cells were older than those who did not (67 years vs 48 years; P = .04). There was a marked relationship between systemic sclerosis subtypes and the presence of a circulating clonal population of T cells. Twelve (43%) of 28 patients with limited cutaneous sclerosis exhibited a circulating clonal population of T cells, whereas only 1 (10%) of the 10 patients with diffuse cutanous sclerosis had evidence of T-cell clonality (P<.01).

CONCLUSIONS

Clonally expanded T cells were more commonly detected in patients with limited cutaneous sclerosis than in those with diffuse cutaneous sclerosis, which is also in accordance with a possible role of clonal T cells in patients with limited cutaneous sclerosis.

Determinants of severity for superficial cellutitis (erysipelas) of the leg: a retrospective study

BACKGROUND: Superficial cellulitis (erysipelas) of the leg is a frequent infectious disease with a favorable outcome, whereas some patients present a serious disease. The determinants of severity for superficial cellulitis (erysipelas) of the leg have not yet been clearly established. In order to determine the characteristics of patients presenting with severe superficial cellulitis of the leg, we analyzed patients with favorable and unfavorable outcome. METHODS: The records of 167 patients referred to Rouen University Hospital for non-superficial cellulitis of the leg were analyzed. Two severity groups of patients were retrospectively defined. Patients in the severe group either died secondary to infection during hospital stay or were hospitalized for a duration at least equal to the 90th percentile (i.e., >21 days of hospitalization). The remaining patients were considered as presenting with non-severe cellulitis. Potential determinants of severity were analyzed by univariate and multivariate analysis based on logistic regression. RESULTS: From univariate analysis, the following general factors were positively associated with severity: advanced age, arterial hypertension, diabetes mellitus, elevated leukocytosis, and elevated neutrophilia. The local factors associated with severity were ulcer of the leg and arteriosclerosis obliterans of the leg. From multivariate analysis, only age (P=0.004), diabetes mellitus (P=0.01), and leukocytosis (P=0.04) appeared to be independently associated with severity. A close to significant association was also found with arteriosclerosis obliterans of the leg (P=0.07). Whereas general complications occurred more frequently in the severe group, no such difference was observed for local complications. CONCLUSIONS: Determinants of severity for superficial cellulitis of the leg include high age and associated medical conditions. Aged patients and patients with diabetes mellitus, elevated leukocytosis, or possibly arteriosclerosis obliterans of the leg should preferably be hospitalized for specific care of associated conditions to avoid the occurrence of general complications.