Spontaneous resolution of intracranial hypertension following radiotherapy for posterior parasagittal meningioma: About two cases and review of the literature

We report the cases of two patients who underwent normofractionated radiotherapy for evolutive asymptomatic parasagittal meningiomas. After completion of radiotherapy, both patients presented severe headache and vomiting episodes without papillar edema. We then decided a "wait-and-scan" strategy because of the slit-ventricles, and symptoms regressed spontaneously. MRI showed significant tumor regression a year after radiotherapy with a newly developed collateral venous drainage system in the first patient and a left, unusually large, superior anastomotic vein in the second. These clinical presentation and radiological evolution are compatible with venous stenosis caused by radiation-induced symptomatic edema, fading after the development of a collateral venous drainage system. The relation between pressure-related headaches and venous anatomy remains unclear in parasagittal meningiomas. These observations underline the importance of the study of venous anatomy when pressure-related headaches are suspected. Further clinical descriptions might help the clinicians to treat these patients' symptoms.

[Selective IgA deficiency]

Selective IgA deficiency (SIgAD) is defined by the European Society for Immunodeficiencies (ESID) as a serum IgA of less than 0.07g/L in patients greater than 4 years old with normal levels of IgG and IgM, normal vaccine responses, and with the exclusion of secondary causes of hypogammaglobulinemia. When serum IgA level is higher than 0.07g/L but two standard deviations below normal for age, the condition may be referred to as partial IgA deficiency, which is quite common. SIgAD is the most common primary immunodeficiency in Europe (1/600 in France) and most patients with SIgAD are asymptomatic (75-90%). The clinical complications associated with SIgAD include recurrent respiratory infections (in particular involving Haemophilus influenza and Streptococcus pneumoniae) and gastrointestinal (mainly due to Giardialamblia), autoimmune and allergic manifestations (anaphylaxis if blood products with IgA are administrated), inflammatory gastrointestinal disease. There is no specific treatment for SIgAD and each patient must be managed individually. While asymptomatic subjects do not need any treatment, it is still necessary for them to be up-to-date with vaccinations. If the patient experiences recurrent infections, prophylactic antibiotics may be beneficial. Immunoglobulin replacement therapy should be considered in patients with SIgAD and concomitant IgG subclass deficiency. Treatment for autoimmune and allergic manifestations is based on current standards of care for specific disease entities. To improve quality of life and reduce morbidity, an interdisciplinary team approach is essential.

Communicating chronic hydrocephalus: A review

Formerly called normal pressure hydrocephalus, communicating chronic hydrocephalus (CCH) is a condition affecting 0.1 to 0.5% of patients over 60years of age. The pathophysiology of this disease is poorly understood, but a defect in cerebrospinal fluid (CSF) resorption appears to be commonly defined as the cause of the neurological disorders. The last important discovery is the description of the glymphatic system and its implication in CCH and CSF resorption. Comorbidities (Alzheimer's disease, microangiopathy, parkinsonism) are very frequent, and involve a diagnostic challenge. The clinical presentation is based on the Hakim and Adams triad, comprising gait disorders, mainly impairing walking, cognitive disorders, affecting executive functions, episodic memory, visuospatial cognition, and sphincter disorders as urinary incontinence (detrusor hyperactivity). The diagnosis is suspected through a set of arguments, combining the clinical presentation, the radiological data of the magnetic resonance imaging (MRI) showing a ventriculomegaly associated with signs of transependymomous resorption of the CSF and disappearance of the cortical sulci, and the clinical response to the depletion of CSF. In the presence of all these elements, or a strong clinical suspicion, the standard treatment will be of a permanent CSF shunt, using a ventriculoatrial or ventriculoperitoneal shunt. The effectiveness of this treatment defines the diagnosis. The clinical improvement is better when treatment occurs early after the onset of the disorders, reaching 75 to 90% of motor improvement.

Giant cell arteritis-related aortitis with positive or negative temporal artery biopsy: a French multicentre study

Objective: To compare the clinical presentation and outcome of giant cell arteritis (GCA)-related aortitis according to the results of temporal artery biopsy (TAB).Method: Patients with GCA-related aortitis diagnosed between 2000 and 2017, who underwent TAB, were retrospectively included from a French multicentre database. They all met at least three American College of Rheumatology criteria for the diagnosis of GCA. Aortitis was defined by aortic wall thickening > 2 mm on computed tomography scan and/or an aortic aneurysm, associated with an inflammatory syndrome. Patients were divided into two groups [positive and negative TAB (TAB+, TAB-)], which were compared regarding aortic imaging characteristics and aortic events, at aortitis diagnosis and during follow-up.Results: We included 56 patients with TAB+ (70%) and 24 with TAB- (30%). At aortitis diagnosis, patients with TAB- were significantly younger than those with TAB+ (67.7 ± 9 vs 72.3 ± 7 years, p = 0.022). Initial clinical signs of GCA, inflammatory parameters, and glucocorticoid therapy were similar in both groups. Coronary artery disease and/or lower limb peripheral arterial disease was more frequent in TAB- patients (25% vs 5.3%, p = 0.018). Aortic wall thickness and type of aortic involvement were not significantly different between groups. Diffuse arterial involvement from the aortic arch was more frequent in TAB- patients (29.1 vs 8.9%, p = 0.03). There were no differences between the groups regarding overall, aneurism-free, relapse-free, and aortic event-free survival.Conclusion: Among patients with GCA-related aortitis, those with TAB- are characterized by younger age and increased frequency of diffuse arterial involvement from the aortic arch compared to those with TAB+, without significant differences in terms of prognosis.

[Inflammatory myopathy following acute meningoccemia in a properdin-deficient patient: A case report]

INTRODUCTION

Myalgia is a classical sign in invasive meningococcal diseases (IMD), but severe and persistent myalgia following an IMD have never been reported to date.

CASE REPORT

A 20-year-old man presented with purpura fulminans and meningitis caused by Neisseria meningitidis serogroup Y, revealing properdin deficiency. Although meningitis symptoms improved after antibiotherapy, initial myalgia of the lower limbs increased, associated with mild rhabdomyolysis. Magnetic resonance imaging (MRI) revealed an increased STIR (Short TI inversion recovery) signal of both quadriceps muscles, without abscess. After exclusion of other causes of myopathy, a post-infectious myositis was diagnosed. A four-week course of corticosteroids led to dramatic improvement.

CONCLUSION

Post-infectious inflammatory myopathy should be suspected in case of severe and persistent myalgia associated with rhabdomyolysis following an IMD, after exclusion of pyomyositis especially. A short course of corticosteroids seems to be effective.

[Paraneoplastic pemphigus: Retrospective study of a case series]

CONTEXT

Paraneoplastic pemphigus (PNP) is a rare condition associated with poor prognosis. It associates polymorphic mucocutaneous manifestations with neoplasia. Diagnosis is difficult because of the various clinical and histological features involved and the lack of specificity of immunological examinations.

METHODS

We retrospectively analyzed the records of patients presenting with PNP in the Poitou-Charentes region between 2000 and 2015.

RESULTS

Seven patients were included. They presented 9 neoplasias (1 lymphoma, 1 melanoma, and 7 carcinomas) diagnosed from 4 months before to 25 months after the occurrence of cutaneous (6/7) and/or mucosal (6/7) polymorphic lesions. Histological examination revealed epidermal acantholysis (7/7), keratinocytic necrosis (4/7), and interface lichenoid dermatitis (5/7). Intercellular deposits of IgG and C3 or along the dermo-epidermal junction were detected with direct immunofluorescence (IF) (7/7). Four of 6 patients tested had positive indirect IF on rat bladder epithelium. Follow-up ranged from 1-132 months with a one-year survival of 85.7%.

DISCUSSION

The clinical and histopathological presentations observed in our patients were polymorphic, with overlap between the clinical and histological features of PNP and classical pemphigus. Prognosis and survival appear better in our series than in the literature. It is possible that in some cases, the association of pemphigus with neoplasia was fortuitous, which might account for the better prognosis. A new consensus on the diagnostic criteria for PNP is needed to help practitioners to consensually diagnose it for prognostic or therapeutic trials.

[Surgical treatment of an auto-immune hemolytic anemia]

INTRODUCTION

Auto-immune hemolytic anemia (AIHA) is a rare cause of anemia, characterized by autoantibodies directed against self red blood cells. It can be primary or secondary, in particular due to lymphoproliferative diseases.

CASE REPORT

We report the case of a 24-year-old woman who presented with a severe macrocytic anemia associated with an ovarian teratoma.

CONCLUSION

Ovarian teratoma is a rare cause of secondary AIHA, with only few cases reported. Its treatment differs from primary AIHA as steroids may be ineffective. Indeed, complete response can only be achieved with surgical excision of the tumor.

A case of Q fever with erythema nodosum

BACKGROUND

Acute Q fever is asymptomatic in 60% of the patients, while the reminder may present with fever, pneumoniae, and hepatitis. Skin manifestations are uncommon including transient punctiform rashes, purpuric, or maculopapular eruptions. Erythema nodosum have seldom been reported.

CASE PRESENTATION

A 37-year-old female presented with fever for 1 month and skin lesions consists of erythematous painful nodule of the legs. Serological testing for Coxiella burnetii was positive. Treatment consisted with doxycycline for 2 weeks. Evolution was favorable. The patient completely recovered and had no evidence of skin lesion 1 month later.

CONCLUSION

Because of its nonspecific clinical presentation, Q fever with erythema nodosum is probably underestimated. Q fever should be evocated when facing unexplained erythema nodosum even if there is not other typical clinical manifestation of Q fever.

[Long-term infectious risks after splenectomy: A retrospective cohort study with up to 10 years follow-up]

INTRODUCTION

Although most infections occur within the first 2 years after splenectomy, the relatively short follow-up reported in many studies may underestimate the frequency of infections. The objective of the study was to determine the incidence of infective outcomes and factors associated with infection after splenectomy by studying a group of patients who underwent splenectomy over a 10-year period.

METHODS

A retrospective and monocentric study of patients who underwent splenectomy between January 1st, 1997 and December 31st, 2004 in a French university hospital. Age, sex, indication for splenectomy, infectious events, death, vaccination and antibiotic prophylaxis were collected in January 2015.

RESULTS

One hundred and sixty-five patients were included. The most common reasons for splenectomy were therapeutic hematological indications (37.5%). Ninety-seven per cent received pneumococcal vaccine. Prophylactic antibiotics were prescribed in 78% of patients. Thirty-seven patients had 42 severe infections with a median incidence rate of 4 years after splenectomy (2 days-12 years). The rate of infection after splenectomy declined over time but 57% occurred after 2 years and 14.3% after 10 years. Respiratory infections were the most common sites of infections. The incidence of infection differed according to age was highest among the elderly (HR=6.2; 95%CI: 1.4-27.1; after 65 years old) and underlying reason for splenectomy (P=0.02). There is no difference with or without prophylactic antibiotics.

CONCLUSION

After splenectomy, the incidence of severe infection declined over time but can occur after 10 years. The onset of infection is linked to age and reason for splenectomy.

[Infectious events during the course of autoimmune diseases treated with rituximab: A retrospective study of 93 cases]

OBJECTIVE

Describe the occurring infections in patients treated with rituximab for an autoimmune disease.

METHODS

Retrospective and monocentric study of 93 adult patients treated with rituximab for autoimmune indications over a nine years period.

RESULTS

Thirty-eight patients suffered from a total of 95 infections. Out of them, 18 patients (19 %) had had at least an infectious episode triggering a hospital admission and/or intravenous treatment. The infections occurred mainly during the first year of the treatment (65 %) and if the courses are repeated (P=0.04). They were mainly pulmonary infections. Severe infections, recorded in 79 % of the cases, were mostly of bacterial origin (43 %) and viral (23 %). Two cases of pneumocystis pneumonia and one case of invasive pulmonary aspergillosis were also recorded. The notion of vaccination was present in less than half of the cases, and 39 % of the patients were already receiving a prophylactic treatment against pneumocystis pneumonia. Patients over the age of 65 years (40 %) had developed less infections (P<0.05). Eight of the initial 93 patients died, half of them because of infectious complications.

CONCLUSION

Infectious complications are frequent, become early and are potentially severe. Imputability to rituximab is not certain. However, this could lead to better codify rituximab prescriptions and take adapted and associated measures in order to facilitate infection prevention and, if an infection does occur, to treat it at the earliest stage possible. The age doesn't seem to be a risk factor.

[Breast lesions as the presenting feature of giant cell arteritis]

INTRODUCTION

Giant cell arteritis most commonly involves the external carotid branches. Although they are less typical, extra-cephalic forms have also been reported.

CASE REPORT

We report the case of a 59-year-old female patient who developed bilateral, painful breast nodules with fever and altered general status since two months. Two weeks later, she presented frontal headache and scalp tenderness. A colour duplex ultrasound of the temporal artery showed a halo sign. The results of a breast needle biopsy were inconclusive but the temporal artery biopsy confirmed the diagnosis of giant cell arteritis. The disease course was rapidly favourable after institution of corticosteroids.

INTRODUCTION

Breast involvement is rare but could be the first sign of giant cell arteritis. The internal mammary artery, which is a branch of the subclavian artery, can be affected and responsible for breast nodules.