[Pleuropulmonary manifestations of necrotising vasculitis]

The pleuropulmonary manifestations of necrotising vasculitis are frequent and polymorphic. If the existence of extrapulmonary signs and the presence of neutrophil polynuclear anticytoplasmic antibodies are helpful for the diagnosis of a bout of vasculitis, the existence of pleuropulmonary symptoms can also make for discussion of infections or iatrogenic effects induced by immunosuppressive treatments.

A rare case of paraplegia complicating a lumbar epidural infiltration

OBJECTIVE

We report the case of a patient who developed paraplegia following a low lumbar epidural steroid injection. Alternative approaches to (or alternative means of) performing transforaminal injections should be considered, in order to avoid devastating neurological complications.

CASE REPORT

A 54-year-old man (who had undergone surgery 14 years earlier to cure an L5-S1 slipped disc with right S1 radiculopathy) presented with low back pain (which had begun 6 weeks previously) and left S1 radiculopathy. During a second infiltration of prednisolone acetate, the patient reported feeling a heat sensation in his legs and concomitantly developed facial flushing. Immediately after the injection, the patient developed complete, flaccid T7 ASIA A motor and sensory paraplegia. Three days later, T2 magnetic resonance imaging (MRI) of the spine revealed a spontaneous hypersignal in the conus medullaris and from T6 to T9, suggesting medullary ischemia. Recovery has been slow; after 4 months of treatment in a physical and rehabilitation medicine department, urinary and sensory disorders are still present (T7 ASIA D paraplegia). The patient can walk 200 m unaided. Three months later, the MRI data had not changed.

DISCUSSION

This is a rare case report of paraplegia following low lumbar epidural infiltration via an interlaminar route. The mechanism is not clear. Most of authors suggest that the pathophysiological basis of this type of complication is ischemia caused by accidental interruption of the medullary blood supply. Direct damage to a medullary artery, arterial spasm or corticosteroid-induced occlusion due to undetected intra-arterial injection could result in medullary infarction. This serious incident should prompt us to consider how to avoid further problems in the future. It also raises the issue of providing patients with information on the risks inherent in this type of procedure.

CONCLUSION

Despite the rarity of this complication, patients should be made aware of its potential occurrence. In the case reported here, the functional prognosis is uncertain.

[Primary pleural lymphoma: a late complication of pleural decortication for tuberculosis: two cases in western countries]

Pleural lymphomas after a long standing pyothorax due to pleuropulmonary tuberculosis are now well identified, but rarely observed in Europe. We report two new cases in a non-immunocompromised patients. The two cases occurred 5455 years following artificial pneumothorax for pulmonary tuberculosis. The patients presented with a localized pleural tumor mass. Histology revealed high-grade lymphomas, diffuse large B-cell lymphoma and anaplastic lymphoma. Serology for Epstein-Barr virus was positive. Pleural lymphomas are an established complication of artificial pneumothorax. Epstein-Barr virus is known to play a crucial role in the pathogenesis, but despite the large number of artificial pneumothorax operations, these lymphomas remain rare, suggesting additional oncogenic factors.

[Diagnosis of adult-onset Still's disease: contribution of biology]

We report one case of adult-onset Still's disease. The diagnosis of this disease currently requires application of Yamaguchi's criteria and then exclusion of infectious, haematological, autoimmune and neoplasic disorders. The place of biology is enhanced with the use of new markers like ferritin and glycosylated ferritin. Low percentage of glycosylated ferritin (<20%) in presence of very high level of ferritin, unexplained prolonged fever with leukocytosis can help to diagnosis. However, glycosylated ferritin is not yet of in routine use.

[A "pulseless" woman with proteinuria!]

Takayasu arteritis, also called pulseless women disease, is a chronic vasculitis of unknown aetiology, which primarily involves the aorta, its branches and coronary and pulmonary arteries. It is an uncommon disease with a variety of presentations and most frequently found in Asia than in Europe. We report a case of a 52-year-old woman, suffering from Takayasu arteritis for 19 years. She was admitted to the hospital for diffuse pain and oedema. Biological tests pointed out proteinuria with renal failure, which was confirmed by a renal biopsy. The association of Takayasu arteritis and renal failure is unusual. This review focuses on the biological manifestations of Takayasu arteritis and on the link between this disease and the renal failure observed in this case.

[A serious complication of sternal puncture: penetrating injury of the ascending thoracic aorta]

INTRODUCTION

Penetrating thoracic aorta wounds are rare but responsible for a high mortality when medical and surgical management is delayed.

OBSERVATION

We report the case of a 71 year-old patient with malignant lymphoma who sustained an accidental penetrating injury of the ascending thoracic aorta while undergoing trephine biopsy of the sternum. He was successfully treated with emergency sternotomy and aortic suture-repair.

CONCLUSION

This case report highlights the limits of sternal trephine biopsy, notably in patients whose bones are weakened by a malignant haematological process, and proposes preventive measures in order to avoid accidents.

[Severe vigilance disturbances: a rare complication of sodium valproate treatment (author's transl)]

Severe vigilance disturbances are rarely observed during sodium valproate treatment. Two such cases are reported, with rapid appearance of mental confusion after starting treatment, associated with an overall slowing of the E.E.G. the plasma levels of the different anti-epileptic agents were normal or only slightly raised and could not have caused the phenomenon. Clinical and electrical signs regressed as rapidly after stopping valproate administration as they had appeared after starting treatment.