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Efficacy and safety of a new oral third generation Cephalosporin, Cefotiam Hexetil (CTM) 200 mg bid were compared with those of Cefixime (CX) 200 mg bid over 10 day duration of treatment. One hundred and twenty two ambulatory adults suffering from chronic sinusitis were randomized by ENT specialists in this multicentre prospective double blind, doubled dummy study. Sinusitis diagnosis evocated in front of fascial pain, purulent nasal discharge and/or obstruction was confirmed with sinus X-ray. Use of antibiotics or corticosteroids concomitantly or 15 days prior inclusion represented one of the major exclusion criterion. One hundred and seventy one patients were evaluated for efficacy analysis (62 and 59 respectively in CTM and CX groups). Regarding demographic data, clinical and radiological signs, the two populations were comparable at inclusion excepted for sex and weight (female: 73% in CTM group versus 47% in CX group). The overall clinical success rate at the end of treatment (cure+improvement) was not significantly different between the two groups (CTM: 82% versus CX: 80%). The incidence of adverse events was less frequent in the CTM group (14.5% versus 19%). In conclusion, CTM 200 mg bid is as efficacious and as well tolerated as CX 200 mg bid in the treatment of chronic sinusitis in adults.

Situations which can be considered at risk for infective endocarditis are those causing a bacteremia, which is necessary for the development of an endocarditis. Such situations can be identified by clinical studies evaluating the rate at which a bacteremia occurs after some procedures or because of lesions, then the risk of endocarditis after such a bacteremia. Without considering preexisting cardiac lesion and age, some situations seem to be at risk of subsequent endocarditis: acute bacterial infection for which antibiotherapy is necessary; procedures involving the mouth with the exception of superficial caries and bloodless supragingival prosthetic preparations; oesophageal dilatation, laser endo-oesophageal procedures, sclerosis of oesophageal varices; colonoscopy and sigmoidoscopy for cancer lesions, gastrointestinal procedures on a potentially infected gastrointestinal tract (cholecystectomy, colectomy...); tonsillectomy and adenoidectomy; naso-tracheal intubation; instrumental procedures involving the ureter or kidney, and prostatic or urinary tract biopsies and surgery; procedures performed on infected skin. In cardiac patients at high risk, in addition to the above retrograde cholangiography, colonoscopy and rectosigmoidoscopy, lithotripsy. In these situations the risk of endocarditis is probably linked to the rate of bacteremia, the size of inoculum, and the bacteria, compared with spontaneous bacteremia without any procedure, where the inoculum is low and bacteria is considered as non pathogenic. A prophylaxis has to be discussed in such situations, which are probably involved in less than 10% of endocarditis.

Objectives: The aim of the present study was to compare the efficiency of pulmonary deposition of pentamidine using the Respirgard II jet nebuliser or the Fison ultrasonic nebuliser with 99m technetium (99m Tc) labelled pentamidine in the current conditions of recommended treatment. The study was designed in three stages, to verify particle size distribution, to validate the isotope labelling, and to compare pulmonary deposition of pentamidine isethionate with the two nebulisers., Methods: Count median aerodynamic diameter and mass median aerodynamic diameter were measured using the velocimetry technique and aerosol dispersion was calculated according to the standard deviation defined by the ratio of diameters between 84.3% and 50% of the total distribution. Stability of labelling was checked both in vitro, by radiochromatography, and in vivo, by the absence of free technetium thyroid fixation after intravenous injection of the preparation to a rat and inhalation by baboons. The direct isotopic technique was used to compare pulmonary deposition of 300 mg aerosolized 99m Tc labelled pentamidine isothionate with the two nebulisers in four HIV patients treated with primary prophylaxis., Results: Count median aerodynamic diameter and mass median aerodynamic diameter (MMAD) were higher with Fisoneb than with Respirgard II. Nevertheless Fisoneb MMAD remained in the optimal range for peripheral deposition. In one patient, pentamidine lung burden was higher using the Respirgard II (13% of dose originally in nebuliser) when compared with the Fisoneb (10.2% of dose originally in nebuliser). A better result was obtained in the 3 other patients with Fisoneb (mean = 14.3%) compared with Respirgard II (mean = 3.8%). In all 4 patients gastric contamination was higher with Fisoneb (mean = 5.2%) as compared with Respirgard II (mean = 2.6%). Cough and bronchospasm were not observed with either device., Conclusion: This study showed that Fisoneb, a practical and cheap nebuliser which has proved to be effective in clinical studies when used for pentamidine nebulisation, leads to correct particle size distribution and pulmonary deposition of the drug. We believe that such studies to evaluate aerosol characteristics should be recommended for any kind of nebuliser.

Numerous studies have established the correlation between antibodies to the core protein p24 of HIV-1 and the progression of the acquired immunodeficiency syndrome. In this study, we analyzed the immune response to two recombinant gag proteins, p24 and p17, in order to evaluate their diagnostic or prognostic significance. Immune response to the immunodominant domain of the transmembrane glycoprotein gp41 was used as a reference. Sera collected from individuals from France and Burundi (Central Africa) at various CDC stages of HIV-1 infection were tested using three sandwich enzyme-linked immunoassays developed with a synthetic peptide corresponding to the immunodominant domain of gp41, SP gp41, or recombinant p24 and p17 cloned and expressed in Escherichia coli. These assays allowed detection of titer antibodies to the three cited antigens. Antibodies to SP gp41 were detected in every HIV-1-positive patient from France and Burundi, generally at a high and stable level. Results obtained with p24 confirmed the value of antibodies to p24 as a prognostic marker only in European and North American populations, since the African population had very high levels of these antibodies even at an advanced stage of the disease. They also confirmed that initial antibody response to p24 is more predictive of outcome than antibody titer change over time. Although antibodies to p17 decline during progression to AIDS, they are frequently absent in French patients at early, asymptomatic stages and therefore could not be used as a prognostic marker. In contrast, antibodies to p17 are significantly less common in African patients with AIDS when compared with symptomless HIV-1-infected African individuals.(ABSTRACT TRUNCATED AT 250 WORDS)

From 1981 to 1990 nine patients suffering from amebic liver abscess were under observation at the Tours hospital. Hepatic amebiasis is scarce in France. Most of the subjects have stayed in endemic areas. Most of the time patients are male adults suffering from fever and abdominal pains. In most cases the liver ultrasonography shows a single cut of the right lobe with variable and non specific aspects. Once the diagnosis has been given a metronidazole treatment must be prescribed. The diagnosis will be confirmed by serology reactions. Clinical supervision is essential. The clinical effectiveness of the treatment is spectacular. Comparatively it will take about six months until serology reactions and liver ultrasonography get back to normal. Management of hepatic amebiasis need exceptionally echo-guided percutaneous puncture or surgery.

Fascioliasis is the parasitic infestation of the liver and biliary tract related to Fasciola hepatica. Bithionol is proposed as the treatment of choice for human fascioliasis without major side effects. However, the efficacy of bithionol has been evaluated in chronic but not in acute fascioliasis. In this study we report on the success of treatment with bithionol in 10 patients with fascioliasis, 8 having acute fascioliasis. The criteria for the diagnosis of fascioliasis were hypereosinophilia, positive immunoelectrophoresis and indirect hemagglutination. Bithionol was given orally to hospitalized patients at the daily dose of 25 mg/kg body wt for 10 days. Three patients with acute fascioliasis received a second course of bithionol 2 or 3 mo after the first because of the recurrence of diarrhea and fatigue in one patient and persistent hypereosinophilia in two patients. All patients were cured. The follow-up period after the first course of treatment was between 16 and 47 mo. No major side effects were observed. We conclude that bithionol is the drug of choice for both acute and chronic fascioliasis. Moreover, its oral administration may allow treatment of fascioliasis in outpatients who do not have serious symptoms.

Isotopic techniques enable to determine the best conditions to aerosolize pentamidine as a preventive treatment of pneumocystis. An original labelling technique of pentamidine isethionate has led into a feasibility study of pentamidine scintigraphy in the monkey, and then to a clinical study. A tracer dose of 2 mg of pentamidine isethionate was diluted into 200 mg of pentamidine mesylate. An ultrasonic nebulizer (TV 6000) and a jet nebulizer (Venticis II) were first compared in four baboons. With the two nebulisers the curves of pulmonary kinetic activity showed a peak 10-15 minutes after the beginning of inhalation and then a plateau. With the ultrasonic TV6000 the pulmonary dose was on average 0.8 mg or 0.4% of the pentamidine aerosolized and the gastric contamination 3.1%. With the Venticis II compressed air apparatus the amount of pentamidine delivered to the deep lung was a mean of 4.2 mg or 2.1% of the aerosolized dose whereas the gastric contamination was only 0.5%. The delivery of the aerosol by the ultrasonic inhaler TV 6000 was then compared with two compressed air inhalers Venticis II and Respirgard II in four patients infected with HIV virus who were submitted to a preventative therapy against pneumocystis. With the ultrasonic TV 6000 the pulmonary dose was 0.8 mg or 0.3%-0.5% of the dose of pentamidine aerosolized and the digestive contamination was 3.1%. The performance of the two compressed air nebulizers Venticis II and Respirgard II were similar. The amount of pentamidine delivered to the deep lung was respectively 12 and 14 mg or 6 and 8% of the dose of pentamidine aerosolized and the digestive activity was 0.2%.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors relate the case of a 24 year old man with deadly evolution in keeping with a paroxysmal paralytic myoglobinuria. Clinical, biological and histological studies of this disease are successively recorded. The pathogenesis is obscure. Symptomatic medical treatment must be supervise in an intensive department.

In this retrospective study, 100 cases of primary staphylococcal septicaemia collected in 5 hospitals over a 2-year period were reviewed. Out of 91 strains of Staphylococcus aureus isolated, 6 were methicillin-resistant, but all 6 came from the same hospital. The mortality rate was 36 per cent. The only prognostic factors elicited were chronic renal failure and septic shock. The 64 patients who survived stayed in hospital for a mean period of 42 days, and 42 recovered without sequelae. Staphylococcal infections remain serious and are not all hospital-acquired.

The team studied 1 200 cases of acute intoxications both accidental and self inflicted, self inflicted poisonings are much more frequent than accidental ones and in general occur more often amongst the young and by women; the median age is about thirty. Barbituric are often the means. There is a progressive increase in the use of tranquilizers and of thymo-analeptics as their use becomes greater. A mixture of poisons increases the dangers because this frequently results in more rapid loss of consciousness; also more than one poison increases the risk of shock and of thermo-regulation, respiratory problems necessitate intubation and artificial respiration which both increase the risk of assification. The characteristics of certain poisons are stressed and in particular the thymo-analeptics; also the supervision of the patients in an intensive care unit.

Laryngeal manifestations are well known and relatively frequent in hypothyroidism. For example horseness, which is due to edematous infiltration of the larynx and vocal cords is often the patient's chief complaint, prompting his initial consultation with a specialist. Of much rarer occurence, however is the concomitant development of laryngeal edema and acute respiratory failure. We report one such case history below.

Effectiveness and tolerance of tiapride were studied in twenty patients in a department of internal medicine. Tiapride was effective against acute manifestations of alcoholism and against agitation, especially in the elderly. There were no serious side-effects, particularly on hemodynamics and vigilance. At the dosage used in our study the analgesic effect of tiapride was both unreliable and transient.

The authors report 87 cases of acute voluntary intoxications with tricyclic antidepressants. They essentially studied the cardiac complications; and conclude that the prognosis is more severe than for other intoxications.

We present two case histories. The first is a case of congenital malaria in a newborn whose Laotian mother immigrated into France 2 years ago. The other is a case of very severe malaria with fetal death in a 28 year old woman who was 8 months pregnant and who had come back to France from Gabon where she had lived for 2 years. The authors wish to draw attention to malaria brought into the country and how serious it can be, and suggest prophylactic measures to be applied for pregnant women and their newborn babies.

Patients' constitutional background, treatment and neurological manifestations were analyzed in a retrospective study of 63 cases of neuromeningeal listeriosis in adults. Age over 60 and coma at the onset were of poor prognosis, but immunodepression (present in only 38% of the cases) did not seem to affect the outcome. The ampicillin-aminoglycoside combination did not appear to improve the vital and functional prognoses more than ampicillin alone. The neurological manifestations observed at the end of hospitalization in 16 of the 42 patients who were cured were not necessarily permanent: among the 13 patients who could be followed up for a mean period of 6.5 years, 5 recovered completely, 5 recovered partially and 3 remained unchanged at neurological examination.

The authors analyse 115 cases of acute fatty liver of pregnancy, proven histologically. Characteristics of the condition is the finding of central nuclei in the hepatocytes containing microvesicular droplets. The disease occurs more frequently in primiparous women (54 per cent) and usually occurs in the third trimester of the pregnancy. A pre-icteric phase usually precedes the jaundice and during that time there is usually vomiting and/or nausa with abdominal pain or anarexia. In 92 per cent of case there is transient loss of consciousness with hepatic encephalopathy. Further tests show that there is more defective liver function than would be expected from the extent of cell lysis; and there is defective renal function. The worst complications are intestinal haemorrhages (48 per cent of cases)--genital bleeding (43 per cent of cases)--shock--diffuse intravascular coagulation and complications associated with coma. Maternal mortality at present runs at 25 per cent and fetal mortality at 60 per cent. The condition does not recur. Early evacuation of the uterus is recommended by most authors and does probably improve the outlook. The various hypotheses concerning the aetiology are discussed.

A 6 years retrospective study (1981-1986) of 153 consecutive cases of HBsAg positive acute hepatitis was carried out to assess the prevalence of delta virus infections in the Indre-et-Loire a district of the Loire Valley in France. Diagnostic value of the various serum markers of delta infection, i. e. HDAg, anti-HD and anti-HD IgM, were evaluated using immunoenzyme assays. During the survey, 22 cases of delta hepatitis were diagnosed (12 co-infections, 10 superinfections). They all involved young adults, 21 of them were drug-addicts, and one young woman was the consort of a drug-addict. In Indre-et-Loire, delta virus infection was responsible for half of acute HBsAg positive hepatitis among drug-users in the last 3 years of our study. Clinical and biological features of acute delta hepatitis were compared to those of the other HBsAg positive hepatitis: two cases of fulminant hepatitis occurred among the 12 co-infections; 4 of 6 superinfection that could be followed up to 6 months developed biopsy-proven chronic active hepatitis. Delta Ag was found constantly during the first week of the disease, its disappearance was always followed by a seroconversion to anti-HD after four weeks. Anti-delta IgM was an inconstant and late marker: it was detected within the first 4 weeks in only one case (a co-infection); it persisted only in superinfections. Our study shows that delta Ag is an efficient serum marker for the early diagnosis of acute delta hepatitis.

Transfusional malaria is an unusual disease. Any fever, happening immediately after blood transfusions must evoke this diagnosis, confirmed by parasites detection in the blood. The treatment is rapidly efficacious. The prophylaxis is at the present time insufficient and would require fluorescent antibody test generalization.

Pericarditis caused by toxoplasma infection is exceptional: 16 cases only have been published since 1943. The authors report a case of Hodgkin's disease associated with, and revealed by, toxoplasmic pleuro-pericarditis, and they review the literature on this complication of toxoplasmosis. Since the infection can be cured and since pericarditis may become chronic and constrictive if untreated, toxoplasmosis should be envisaged and confirmed or infirmed by serological tests in all patients presenting with pericarditis of uncertain origin. Provided it has not reached the chronic stage, toxoplasmic pericarditis responds well to the conventional treatment with pyrimethamine and sulfonamides.

Five hundred and three patients with tetanus were hospitalized in the intensive care unit of "Hôpital Bretonneau" between January 1st, 1960 and December 31, 1979. An analysis of all these 503 cases is undertaken herein. The results of a similar study by the authors concerning 254 cases of tetanus were published in this journal in 1971 [16]. Frequent reference is made to the earlier study in order to evaluate any differences in prognosis which have occurred since that time.

An adrenal gland tumor associating of both a pheochromocytoma and a ganglioneuroma was discovered upon its fissuration in a 58-year-old male having a family history of neurofibromatosis. The patient's clinical course was fatal due to complications of necrotizing enteritis which was discovered at laparotomy. The association of pheochromocytoma, ganglioneuroma, and "café au lait" spots in the same patient illustrates the polymorphism of neural crest dysgenetic pathology.

The authors report a case of myelopathy associated with macrotic anemia. The prior inefficacy of treatment with B1, B6 and B12 vitamins, in spite of a normal Schilling test, suggested the possibility of folate deficiency, the concentration of which was found very low in the serum (1.5 mg/ml). The addition of folic acid to the vitamins already administered without success, was followed by rapid recovery of the anemia and a frank neurological improvement maintained after 10 months follow-up. The rare similar cases observed in the world literature are analysed here. The other neurological manifestations, due to folate deficiency, the etiological circumstances and the methods of diagnosis are recalled.

In industrial countries protein-calorie malnutrition (PCM) is a frequent cause of hospital morbidity and mortality. In this study, 88 hospital patients were evaluated: 44 (25 men and 19 women) aged from 20 to 80 years) with PCM, and 44 without malnutrition; the two groups were matched with regard to sex, age and height. The following parameters were determined: arm muscle surface, whole-body muscle mass, proportion of body fat, serum albumin (Alb), prealbumin (PA), retinol-binding protein (RBP), transferrin, thyroxine-binding protein, thyroxine, triiodothyronine, reverse triiodothyronine and total complement. Anthropometric measurements were validated by planimetry of a computerized tomographic section of the arm in 60 patients. There were significant differences between the two sexes in anthropometric values. Alb, PA and RBP values were different in men and RBP only in women; all other biochemical parameters were the same in both sexes. Thus, the group with PCM could be distinguished from the control group by anthropometric values and RBP values. Anthropometric parameters have been reported as being more specific of PCM than biochemical parameters, but since the latter are considered more sensitive, both complement each other and must be taken into account.

83 patients with human immunodeficiency virus (HIV) infection (CDC groups II, III, or IV-A) were randomised in a crossover trial of sodium-diethyldithiocarbamate (ditiocarb sodium, 'Imuthiol') (10 mg/kg body weight given orally once a week) against placebo. Each arm of the trial lasted 16 weeks. The disease did not progress to CDC-defined acquired immunodeficiency syndrome in the ditiocarb group but did so in 4 patients in the placebo group (3 between week 0 and 16, 1 between week 17 and 32). Ditiocarb was also associated to a significantly greater extent than placebo with relief of constitutional symptoms, improvement in clinical status (including shrinkage of enlarged spleen and lymph nodes), and improvement in immune function (as measured by CD4+ cell count and skin test reactivity). When placebo was replaced by ditiocarb, similar improvements were observed, whereas symptoms slowly reappeared and CD4+ cell levels progressively declined when ditiocarb treatment was replaced by placebo.

The spectrum of 182 hospital Mycoplasma pneumoniae infections, collected over a five-year period, is reviewed. The diagnosis was based on complement fixation test. Mycoplasma infection was encountered mainly in young people, mean age 29 years. Eighty-four per cent presented with an atypical pneumonia, 33 per cent had extrapulmonary manifestations mainly neurological and cutaneous. Acute respiratory failure occurred in 32 cases. Only 5 patients died. Macrolides or tetracyclines remain the most effective antibiotics but spontaneous recovery is usual.

A 30-year-old homosexual man developed multiple skin umbilicated lesions resembling molluscum contagiosum. Initially the lesions were on his face but they rapidly spread. Histopathology and mycologic cultures of a skin biopsy revealed cryptococcus neoformans which was also identified in cerebrospinal fluid and in bronchoalveolar washings. The patient had fever, weight loss, generalized lymph node enlargement, depletion of the T helper subpopulation and positive HIV-1 serology. During treatment with flucytosine and amphotericin B, the skin lesions regressed in 3 months (cryptococcus neoformans disappeared in the cerebrospinal fluid and skin within one and five weeks, respectively). Our case demonstrates that molluscum contagiosum-like skin manifestations may be caused by cryptococcal infections. So it is necessary to perform skin biopsy in HIV seropositive patients with skin lesions resembling molluscum contagiosum, to diagnose mycotic infections, and especially cryptococcosis. Cutaneous cryptococcosis was, in this case, the first symptom of AIDS.