Liver Involvement in Patients With PiZZ-Emphysema, Candidates for Lung Transplantation

Information about the prevalence and nature of liver disorders in adults with alpha1-antitrypsin deficiency is scarce. At our center, systematic liver biopsy screening is part of the evaluation before lung transplantation (LT) in the emphysema patients with the PiZZ phenotype. Our aim was to report our experience with this prospective screening. Clinical, liver function, and imaging parameters as well as liver histology data were analyzed for 23 consecutive adult patients with PiZZ severe emphysema referred to our center for consideration of LT from 2006 to 2014. Overall 20 (87%) featured chronic liver disease characterized by a chronic inflammation and/or a significant portal fibrosis on histology. Two of the 23 patients (8.7%) had septal fibrosis according to the Metavir and Ishak scores and met our definition of severe chronic liver disease. They were both clinically asymptomatic with normal liver function tests. On abdominal ultrasonography, the liver appeared normal in one patient and with abnormal contours in the other. Our data indicate that in adults with PiZZ-related emphysema being evaluated for LT, most patients had some histologic involvement. The prevalence of severe liver dysfunction is <10%.

Complications following intravesical bacillus Calmette-Guerin treatment for bladder cancer: a case series of 22 patients

BACKGROUND

Intravesical bacillus Calmette-Guerin (BCG) therapy is an effective and widely used treatment for superficial bladder carcinoma. Local complications are frequent whereas systemic complications are rare but can be serious, and their management is not well known.

METHODS

We describe retrospectively the records of 22 patients treated in 3 infectious disease departments, for complications related to intravesical BCG therapy as treatment of bladder cancer.

RESULTS

All the patients were male, with a median age of 68 years (range 56-88). Complications occurred after a median of 5 instillations (range 1-11) and were observed within 24 h following BCG instillation for 14 patients. Common symptoms were fever (n = 20), impaired general condition (n = 14), and shortness of breath (n = 7). Six patients had a systemic septic reaction leading to transfer into the intensive care unit for five of them. Lung infiltration was the most frequent presentation (n = 11). Mycobacterium bovis was isolated from only two patients, but histology showed the presence of a granuloma in nine patients. Antimycobacterial treatment was initialized in 17 patients; the outcome was favorable in 16 patients, with a median length of symptoms resolution of 22.5 days (range 5-425 days). Eleven patients received corticosteroids in addition to specific treatment and had a more rapid improvement. One patient died with disseminated BCGitis proved by biopsy.

CONCLUSIONS

Complications following intravesical BCG therapy are rare but can be severe and fatal. Histology seems to be the method that contributes most in confirmation of the diagnosis. Antimycobacterial therapy is effective, and probably more efficient when combined with corticosteroids, but the regimen and duration of the treatment are not standardized.

Lytic bone lesions in lupus-associated myelofibrosis

Myelofibrosis is associated with numerous causes other than hematologic malignant neoplasms, including autoimmune diseases. We describe a 44-year-old woman who suffered bone lytic lesions with extramedullary haematopoiesis in the setting of myelofibrosis associated with systemic lupus erythematosus.

[Epidemiology and delays in the management of 355 patients with lung cancer]

BACKGROUND

The epidemiology of patients with lung cancer in a Seine-Saint-Denis hospital are reported, as well as causes of diagnostic and therapeutic delays in their management.

MATERIAL AND METHODS

Retrospective analysis of cases diagnosed from January 1, 1997 to December 31, 2003.

RESULTS

Of 355 cases, 15.8% were women; the average age was 62 +/- 11. Mean smoking history was 50 +/- 24 pack years. Women were more likely to be non-smokers than men (16% and 1% respectively, p < 0.01) and were more likely to present at a young age (under the age of 50: 26.8% and 13.7% respectively, p < 0.05). Among women, adenocarcinoma was more frequent (41% vs. 25%, p < 0.05), and often presented with stage IV disease (74%). Squamous cell carcinoma occurred more frequently with increasing age (18.7% vs. 32.2% before and after the age of 60, p < 0.01). The median pre hospital, diagnostic and treatment delays were respectively 30, 10 and 9 days, the global delay from first symptom to treatment was 62 days. Surgery increased therapeutic delay by 20 days.

CONCLUSION

Our results are complementary to those found in KBP-2000-CPHG study. Young women are diagnosed at a late stage. Influence of delays on prognosis is not proved and require others studies.

Sepsis due to Clostridium perfringens after pregnancy termination with feticide by cordocentesis: a case report

We report a case of sepsis due to Clostridium perfringens after termination of pregnancy at 22 weeks with feticide by cordocentesis. Three weeks earlier, the 41-year-old patient had undergone an amniocentesis and a full trisomy 13 karyotype had been discovered. Feticide was performed by injection of thiopental and potassium chloride after percutaneous umbilical foetal blood sampling through the same needle. The patient delivered vaginally with signs of chorioamnionitis and septicaemia. She recovered under broad-spectrum antibiotherapy. C. perfringens was present in maternal blood cultures, placental smears and foetal organs. We discuss the possible mechanisms of infection by C. perfringens, including inoculation of intestinal germs.

[Intraductal mucinous tumor of the pancreas: report of a clinical case]

A 49-year-old diabetic patient with abdominal pain was found at ultrasonography and computed tomography to have a cystic mass in the head of the pancreas with dilatation of the main pancreatic duct. The head of the pancreas and the duodenum were removed surgically. Examination of the operative specimen showed chronic pancreatitis, dilatation of the main pancreatic duct, and impacted mucus in the secondary ducts with villous proliferation of the ductal epithelium, thus allowing a diagnosis of intraductal adenomatosis. There was no evidence of malignancy. The resection margin was involved, and consequently the remainder of the pancreas was removed six months after the initial surgical procedure. A review of the literature showed that intraductal adenomatosis tends to spread and carries a high risk of malignant transformation. Surgery is required because of the risk of pancreatic duct obstruction and pancreatic cancer. Intraductal papillary tumour of the pancreas shares many characteristic with other adenomatous proliferation of the gastrointestinal tract (colorectal villous adenoma, bile duct adenomatosis) including the presence of villous structures with increased mucus production, a tendency to spread massively, and a high risk of malignant transformation.

[MALT lymphoma of the lacrimal apparatus (mucosa-associated lymphoid tissue)]

Mucosa-associated lymphoid tissue lymphoma can occur in various localizations. We describe the case of a patient presenting bilateral MALT lymphoma involving a lacrimal gland and a lacrimal duct. Biopsy specimens are required for histologic diagnosis. Such low-grade lymphomas are generally treated medically with radiotherapy or chemotherapy. Prognosis is generally favorable. A complete work-up is required to determine extension. These patients should be followed regularly.

[Fronto-naso-ethmoido-sphenoido-maxillo-orbital mucocele with ophthalmologic presentation]

PURPOSE

We present a case of a large mucocele pressing the orbit forward and compared our findings with those reported by others.

CASE REPORT

A 23-year-old woman was examined for an inflammatory tumor of the internal canthus. She had a 6/10 vision loss of the left eye, diplopia, and non-axial exophthalmos. CT scan and magnetic resonance imaging evidenced a huge sinus mucocele behind the orbit. Surgery using the paralateronasal approach was performed. Pathology confirmed the diagnosis of mucocele.

DISCUSSION

Ophthalmic complications of mucoceles result from tumor growth leading to compressive optic neuropathy or even compression of the chiasma. A sinus mucocele should be suspected upon indirect clinical signs and lead to neuroradiological explorations. Magnetic resonance imaging reveals iso- or high signals on T1-weighted sequences and high signal on T2-weighted sequences. MRI evidences intracranial or orbital extension. CT scan reveal the degree of bone erosion. Prognosis is favorable after surgical treatment. It is important to correctly diagnose mucocele on the basis of clinical and neuroradiological findings in order to propose early surgery and prevent permanent visual loss by compressive optic neuropathy.

[Clear cell sarcoma of the kidney in a young adult]

We report a case of clear cell sarcoma of kidney (CCSK), in a young adult. This highly malignant renal tumor usually arises in children of one or two year old and represents 4% of renal tumors. The aggressivity of this tumor and its affinity to give bone metastasis imply to recognize it in order to institute appropriate chemotherapy.

[Value of proctosigmoidoscopy with bacteriological culture of colonic biopsies in the etiological diagnosis of post-antibiotic acute diarrhea in adults. Prospective study in 24 patients]

The aim of this study was to analyse the interest of proctosigmoidoscopy and biopsies microbiology in antibiotic-associated acute diarrhea in adults. Between February 1993 and October 1995, we have studied prospectively 24 patients with antibiotic-associated acute diarrhea. Ages ranged from 17 to 83 years. They had taken antibiotics: amoxicillin (n = 8) amoxicillin-clavulanic acid (n = 11), cephalosporinia (n = 3), cotrimoxazole (n = 1), macrolide (n = 1). For each patient, 2 stool cultures with Cytotoxin assay for Clostridium difficile and 3 fecal samples for parasitic enteropathogens were collected. Proctosigmoidoscopy with biopsies microbiology was carried out in all patients. Stool culture was always negative but colonic biopsies cultures were positive with Klebsiella oxytoca in 7 patients. Cytotoxin assay of C. difficile was positive in 11 patients. Proctosigmoidoscopy permitted also diagnosis of 2 pseudomembranous colitis without cytotoxin assay of C. difficile. Proctosigmoidoscopy permitted diagnosis of 83% of antibiotic-associated acute diarrhea. Complementary to Cytotoxin assay of C. difficile, it should be necessary in antibiotic-associated acute diarrhea in adults.

[Pancreatic involvement, ascites and diarrhea in idiopathic hypereosinophilic syndrome]

We report a new case of idiopathic hypereosinophilic syndrome with multivisceral digestive failure. After an erroneous diagnosis of pancreatic cancer, the pathological examination of pancreaticoduodenectomy specimen demonstrated pancreatic fibrosis with eosinophilic infiltration without gastritis or duodenitis. The diagnosis of idiopathic hypereosinophilic syndrome was made three months later upon the classical criteria: a) blood eosinophilia of 1.5 G/L or more, persisting for more than 6 months; b) lack of evidence for any other recognised cause of eosinophilia: c) multiple organ systemic involvement: rheumatologic, cutaneous and digestive (pancreatitis, ascites and diarrhoea): d) previous history of allergic disease and increased plasmatic IgE levels; e) absence of leukemic markers. This case emphasises the difficulty in classifying eosinophilic infiltration of the gut and the possibility of transitional forms between eosinophilic gastro-enteritis and idiopathic hypereosinophilic syndrome. We argue that in case of eosinophilic infiltration of the gut, systematic research of multiple organ systemic involvement is mandatory.

[Value of rectosigmoidoscopy with bacteriological culture of colonic biopsies in the diagnosis of post-antibiotic hemorrhagic colitis related to Klebsiella oxytoca]

We report 7 cases of antibiotic-associated and hemorrhagic colitis due to Klebsiella oxytoca. The diagnosis was performed by sigmoidoscopy with bacteriological biopsy culture.

PATIENTS AND METHODS

Nine patients, aged 25-83 years, were hospitalized from February 1993 to October 1995 with hemorrhagic acute diarrhea following antibiotic treatment: amoxicillin (n = 3). amoxicillin-clavulanic acid (n = 4), cephalosporine (n = 2). All patients have had two stool samples cultures including Clostridium difficile toxin detection. Sigmoidoscopy with collection of biopsy specimens for bacteriological cultures was performed routinely.

RESULTS

Endoscopic findings established the diagnosis of colitis in all cases: rectitis (n = 1), diffuse left colitis (n = 4), segmental left colitis (n = 4). The lesions were erythematous and purpuric (n = 5) or ulcerative (n = 4). Stool culture was normal in all cases but Klebsiella oxytoca was isolated in 7 cases (78%).

CONCLUSIONS

Sigmoidoscopy and bioptic microbiology ensured the diagnosis of antibiotic-associated hemorrhagic colitis due to Klebsiella oxytoca.

[Multinucleated cell angiohistiocytoma. Report of 6 cases]

Multinucleate cell angiohistiocytoma is a recently described entity. It is a benign vascular proliferation. Clinically, it is characterized by violaceous red papules, often mimicking Kaposi's sarcoma. Acral sites and face were the commonest sites. The six patient's age was between 41 and 64 years and sex ratio was equal. Microscopic features were an increased number of blood vessels together with mononucleated and multinucleated histiocyte-like cells with scalloped borders. Staining of mononucleated cells with CD68, anti vimentin and anti factor XIIIa antibodies emphasized a fibrohistiocytic origin. Loss of factor XIIIa expression in multinucleate cells gets clue to think that these cells are dedifferenciated.

[Intraductal pancreatic adenomatosis. Apropos of a new case]

A 49-year-old diabetic patient with abdominal pain was found upon ultrasonography and computed tomography to have a cystic mass in the head of the pancreas with dilation of the main pancreatic duct. The head of the pancreas and duodenum were removed surgically. Examination of the operative specimen showed chronic pancreatitis, dilation of the main pancreatic duct, and impacted mucus in the secondary ducts with villous proliferation of the ductal epithelium, establishing the diagnosis of intraductal adenomatosis. There was no evidence of malignancy. The resection margin was involved, and consequently the remainder of the pancreas was removed six months after the initial surgical procedure. A review of the literature showed that intraductal adenomatosis tends to spread and carries a high risk of malignant transformation. Surgery is required because of the risk of pancreatic duct obstruction and pancreatic cancer. Intraductal adenomatosis of the pancreas shares many characteristics with other adenomatous proliferations of the gastrointestinal tract (colorectal villous adenoma, bile duct adenomatosis), including presence of villous structures with increased mucus production, a tendency to spread massively, and a high risk of malignant transformation.

[The value of rectosigmoidoscopy and the bacteriologic culture of colon biopsies in the etiologic diagnosis of acute diarrhea of adults. A prospective study of 65 patients]

The goal of this study was to evaluate the contribution of sigmoidoscopy with bioptic microbiology to the etiologic diagnosis of acute diarrhea in adults. Patients and methods. Sixty-five patients with acute diarrhea were included prospectively from February 1993 to November 1994. Ages ranged from 17 to 83 years. In each patient, two stool samples were cultured and three examined for parasites. Clostridium difficile toxin was looked for in the 18 patients who had taken antimicrobials before onset of the diarrhea. Sigmoidoscopy with collection of biopsy specimens for bacteriologic cultures was performed routinely. Results. A pathogenic organism was identified in 35 patients (54%). Eighteen patients (28%) had positive stool cultures. Clostridium difficile toxin was detected in six patients. Colonic biopsy cultures were positive in 26 patients (40%). Endoscopic findings established the diagnosis of pseudomembranous colitis with negative tests for C. difficile toxin in two patients, diverticulitis in one, ischemic colitis in two, and cryptogenic colitis in seven. Conclusions. Sigmoidoscopy ensured the diagnosis in over 72% of cases of acute diarrhea. This investigation complements stool cultures and should be done routinely in adults with severe acute diarrhea.

[CD8 hyperlymphocytosis syndrome and human immunodeficiency virus infection: 5 cases]

A retrospective study on 202 consecutive patients with HIV infection was reviewed. A particular syndrome with blood CD8 lymphocytosis > 1 500/mm3, associated with a diffuse lymphocytic infiltrate histologically proved in the tissue of different organs was present in five patients. Clinical findings were variable, depending on the location of visceral infiltrate by activated, polyclonal lymphocytes of CD8 phenotype: interstitial pneumonia (n = 3), parotid gland enlargement with sicca syndrome (n = 2), pseudo-tumoral splenomegaly (n = 1), peripheral neuropathy (n = 1), superficial generalized lymphadenopathy (n = 5). This syndrome occurred early during HIV infection. All patients had a blood CD4 lymphocyte count > 200/mm3. This disorder is a host immune response, sometimes associated with the presence of some HLA antigens: HLA-DR5 or HLA A1 B8 DR3. Whether this immune response is specific or not, whether outcome of HIV infection depends on hyper CD8 lymphocytosis remains to be proved.

Pressor responses of rat isolated tail arteries to contractile stimulation after methylene blue treatment: effect of adventitial versus intimal entry

To test the hypothesis that drug entry site (intimal vs. adventitial surface) may be an important determinant of methylene blue (MB) action on vascular reactivity to contractile stimulation, we used preparations of rat isolated tail arteries perfused at constant flow (2 ml/min). Perfusion pressure changes reflecting vascular responses to cumulative addition of phenylephrine (PE) or dopamine (DOP) were recorded before and after MB addition (2.5 x 10(-4) M final concentration) at the intimal or adventitial surface. Intraluminal addition of MB resulted in strong potentiation of subsequent responses to intimal contractile stimulation using PE or DOP. This effect was not observed when MB was added at the adventitial surface. These results suggest that drug entry site is an important determinant of MB action on vascular responsiveness in the rat tail artery and might account for the divergent results in the literature on the vascular action of MB.

[Human Pasteurella multocida infections. Value of serological diagnosis]

In five human cases of Pasteurella multocida infection, high titres of specific antibodies were found by indirect haemagglutination (capsular antigens) and agglutination (somatic antigens). The specificity of the antibodies fitted with the serotypes of the isolated strains (three A 3 and two A 7). Subsequent changes in antibody titres in human beings were similar to those observed in animals. The risk of this animal-acquired infection being probably underestimated in medical practice, the usefulness of these tests in human beings is discussed.

Consequences of renal morphologic damage induced by inhibition of converting enzyme in rat renovascular hypertension

The consequences of morphologic changes in the kidney distal to a stenosis induced by chronic administration of a converting enzyme inhibitor were determined after induction of experimental renovascular hypertension in rats. The relationship between changes in morphology in the clipped kidney and diuresis, creatinine, and mortality was studied by converting a two-kidney, one-clip model into a one-kidney, one-clip model after 1 month of converting enzyme inhibition. The right renal artery was constricted with a clip of 0.2 mm diameter to increase blood pressure, the left kidney was left untouched. After 1 month, systolic blood pressure had increased to 173 +/- 27 mm Hg in the clipped animals (n = 47) compared with 139 +/- 8 mm Hg in sham-operated animals (n = 15; group 1). An inhibitor of angiotensin-converting enzyme, MK421 (2 mg/kg, po), or an equivalent volume of vehicle was then administered daily for 1 month. After treatment with the converting enzyme inhibitor, blood pressure (148 +/- 28 mm Hg) was virtually identical with that of a sham-operated, vehicle-treated control group (145 +/- 16 mm Hg, n = 15), and was significantly lower than that of untreated hypertensive rats (186 +/- 30 mm Hg, n = 17) (group 2). The weight of the left kidney was increased in the untreated hypertensive animals as compared with sham-operated controls (1260 +/- 168 mg for group 2 versus 1075 +/- 100 mg for group 1). After treatment with MK421, the weight of the contralateral kidney (1472 +/- 190 mg) was further increased. After 1 month of treatment with MK421 or vehicle, the unclipped left kidney was removed from all animals. The treated animals were then randomly divided into two groups: one in which treatment with MK421 was stopped (treated/untreated, n = 24; group 3) and a second in which the treatment was continued (treated/treated, n = 23; group 4). The ability of the rats to excrete a water load of 15 ml was then examined 12 hours after removal of the unclipped left kidney. In the two groups of treated rats, the urinary excretion of the water load was decreased and frequency of oliguria was increased as compared with controls and hypertensive untreated rats. Survival rates were affected by the treatment: 3 deaths occurred in the hypertensive untreated group 2, 10 in the treated/untreated group 3, and 12 in the treated/treated group 4. The majority of these deaths could be attributed to renal insufficiency.(ABSTRACT TRUNCATED AT 400 WORDS)

Carbamazepine-induced acute cholangitis

We report the case of a patient with carbamazepine-induced cholestasis in whom histologic examination showed acute cholangitis. This type of lesion broadens the spectrum of carbamazepine-induced liver injury which also includes granuloma and hepatocellular necrosis. Its association with marked hypereosinophilia suggests that carbamazepine may cause acute cholangitis through an immunoallergic mechanism.

Specific antibody response to Pasteurella multocida

Six patients with culturally proven Pasteurella multocida infection were evaluated serologically. The infections were 1 foot abscess, 1 septicemia, 3 bronchitis and 1 bronchopneumonia. Most of them were elderly women closely exposed to pets or domestic animals. The serotypes of the strains were determined in 5 cases (3 A3, 2 A7). Specific antibodies against capsular and somatic antigens of P. multocida were determined by indirect hemagglutination and agglutination respectively. The antibodies were strictly directed against the capsular and somatic specificities of the isolated strain. The range of the serum antibody titers were 20 to 2,560 to capsular antigens and 5 to 640 to somatic antigens within 2 weeks after the first clinical signs of infection. Several months after successful treatment, the capsular antibodies were lower while the somatic antibodies had almost disappeared. These findings suggest a good sensitivity for these serologic methods in active cases. Declining antibody titers follow healing. Cross-reactivity of the serologic tests with other bacteria was not observed. Serologic diagnosis of P. multocida infections is a possible alternative to direct diagnosis when cultures are negative or when unusual localizations must be confirmed.

Effects of antihypertensive treatment in one-clip, two kidney hypertension in rats

In order to investigate the consequences of antihypertensive therapy on hormonal and renal parameters in one-clip, two kidney renovascular hypertension, we compared the effects of converting enzyme inhibition (CEI) with those of tripletherapy (clonidine, dihydralazine and furosemide) in this experimental model in rats. The treatment period was initiated four weeks after application of the clip and was continued for five weeks. In plasma, renin was increased and renin substrate was negatively correlated to plasma renin. Hypertension was associated with activation of the renin angiotensin system in both plasma and kidney. The degree of activation of the renin-angiotensin system in the clipped kidney and its suppression in the unclipped kidney was evaluated by two methods, renal renin content and semi-quantification of juxtaglomerular hyperplasia by immunofluorescent renin. These two methods were correlated. During the treatment period, average systolic blood pressure was 144 +/- 13 mmHg in the CEI treated group (HT1) which was not significantly different from the value found in the sham-operated group (139 +/- 4 mmHg; C2). Blood pressure, however, was lowered only to 173 +/- 18 mmHg in the group treated with tripletherapy (HT2). In control hypertensive animals, the wt of the clipped kidney did not decrease whereas significant hypertrophy was present in the unclipped kidney. Tripletherapy did not alter this relationship, whereas converting enzyme inhibition decreased kidney wt in the clipped kidney and increased further the hypertrophy of the contralateral unclipped kidney. A histological examination revealed that hypertensive microangiopathy was a predominant feature in the unclipped kidney of the untreated hypertensive group and of the group treated with tripletherapy, these lesions were completely absent in the CEI treated group. In the CEI treated group, however, ischemic lesions during this treatment were found to be decreased in the contralateral unclipped kidney and increased in the clipped kidney by comparison with untreated hypertensive rats. These renal lesions observed in the clipped kidney were most likely related to the normalization of blood pressure or to a disturbance of intrarenal mechanisms normally mediated by the renin-angiotensin system during stenosis of a renal artery.