Search

Resume Propos Les permanences d’acces aux soins de sante (PASS) sont un dispositif qui permet aux patients vulnerables economiquement, sans couverture sociale de se faire soigner. Il existe peu de donnees sur le profil des patients frequentant ces centres a Paris. L’objectif de cette etude est de decrire le profil socio-demographique et sanitaire de ces patients et d’analyser les motifs de leur recours a ce type de structure. Methodes Il s’agit d’une etude descriptive transversale par questionnement direct des patients s’etant presentes a la consultation de 5 PASS de centres hospitalo-universitaires parisiens entre avril et mai 2008. Resultats Au total, 581 patients ont ete inclus. L’âge moyen etait 42 ans, 65 % etaient des hommes. Seulement 50,9 % declaraient avoir un salaire et 38,4 % beneficiaient de la securite sociale de base. La moitie des patients n’avaient pas de domicile fixe et la majorite (80 %) etait d’origine etrangere. Les principaux motifs evoques pour consulter une PASS etaient l’existence de consultations sans rendez-vous, des raisons financieres et un suivi dans le meme hopital. Plus de la moitie avaient une maladie chronique alors que seulement un tiers d’entre eux beneficiaient d’un suivi medical. Un probleme psychologique ou psychiatrique etait identifie chez 17 % des patients. Le pronostic vital, en l’absence de traitement, classe en 3 stades bon, moyen ou mauvais, etait considere comme moyen ou mauvais chez 48,7 % d’entre eux. Conclusion La population recue dans les PASS est en situation de precarite evidente, de plus ces patients sont porteurs de pathologies plus lourdes que dans la population generale.

Resume Propos. – Les mastocytoses systemiques sont des maladies rares, caracterisees par une proliferation mastocytaire au sein de differents organes. Les manifestations cliniques sont de deux types : celles liees au relargage des mediateurs mastocytaires et celles liees a l’envahissement des differents organes par les mastocytes pathologiques, ces dernieres definissant les formes agressives de la maladie. Jusque recemment, le traitement n’etait que symptomatique et sans effet sur le syndrome tumoral. Actualites et points forts. – Des progres ont ete faits ces dernieres annees dans la comprehension de la maladie avec la mise en evidence d’une mutation du proto-oncogene c-kit et l’assimilation des mastocytoses systemiques a un syndrome myeloproliferatif. Perspectives et projets. – De nouvelles approches therapeutiques fondees sur l’experience acquise dans le traitement de certains syndromes myeloproliferatifs sont en cours de developpement. Dans cette optique, l’association interferon–cytarabine d’une part et la cladribine d’autre part, constituent des voies prometteuses. Enfin, une nouvelle famille de molecules actives sur la proteine c-kit, les inhibiteurs de tyrosine kinase, a recemment demontre avec l’imatinib mesylate une grande efficacite dans le traitement des tumeurs stromales gastro-intestinales (GIST) comportant une mutation de c-kit. Par analogie, il est possible d’esperer une reponse chez les malades porteurs d’une mutation de c-kit sensible a ces inhibiteurs.

Chronic aortic dissection presenting as a prolonged febrile disease. Purpose. — Aortic arch dissection may be sometimes misdiagnosed due to the lack of mild to moderate chest pain. Definite diagnosis is often made while dissection has already occurred more than 15 days ago, being thereafter considered as chronic. Aortic dissection may then present as a prolonged febrile illness with fever and/or inflammation as main symptoms, with little or no pain. Methods. — We retrospectively reviewed cases of chronic aortic dissections seen in a department of internal medicine and a department of neurology between 1975 and 1992. Results. — We report six cases of patients presenting with aortic dissection and describe their outcome and treatments after the diagnosis was made based on either thoracic computerized tomography or trans-esophageal echocardiography evidence. Four patients had surgical aortic arch repair while one patient was treated with beta-blockers. Conclusion. — Chronic aortic dissection has rarely been reported to cause fever or increased sedimentation rate. Treatment has to be discussed between medical and surgical teams involved in the therapeutical management of these unusual patients.

Resume Propos Rechercher une interaction reciproque entre le deroulement d'une grossesse et le profil evolutif d'une sarcoidose. Methodes Tous les evenements obstetricaux survenus chez 11 femmes suivies par ailleurs pour une sarcoidose prouvee par histologie ont ete notes. Pour chaque grossesse etudiee, le deroulement de la grossesse et l'influence de la grossesse sur l'evolution de la sarcoidose ont ete enregistres. Resultats Sur 33 grossesses etudiees, 23 ont permis la naissance de nouveau-nes en bonne sante (cinq fausses couches, quatre interruptions volontaires, une interruption therapeutique). Le seul fait notable a ete la decouverte de six hypotrophies fœtales, dont trois sont survenues chez des patientes ayant une sarcoidose active traitee par prednisone durant la grossesse. Il n'a pas ete observe de rechute pour les sarcoidoses gueries, et les sarcoidoses inactives en debut de grossesse le sont demeurees. Les sarcoidoses actives en debut de grossesse avaient une evolution variable: amelioration (un cas), stabilisation (deux cas) et aggravation (deux cas). Durant l'annee qui a suivi l'accouchement, quatre rechutes ont ete notees, ainsi que les premiers signes de sarcoidose dans deux cas. Conclusion En dehors d'un risque possible, mais non certain d'hypotrophie, il ne semble pas exister d'effet deletere de la sarcoidose sur le deroulement de la grossesse. La grossesse ne semble pas interferer sur le mode evolutif de la sarcoidose. Compte tenu du risque de rechute durant le post-partum, une surveillance clinique et radiologique doit etre proposee a ces patientes.

In the context of the French National Health Service, a free access to healthcare facilities (the PASS: "permanence d'accès aux soins de santé") has been implanted in 2000 for patients without health insurance or those dealing with financial hardship. There is few data about socio-demographic characteristics of the patients using these services. The objective of this study was to provide descriptive data about socio-demographic characteristics and motivation of those patients who use these clinics.This descriptive cross-sectional study was conducted between April an May 2008, in 5 PASS clinics from academic tertiary hospitals in Paris. Descriptive data on patient were collected by general practitioners at the end of their consultations.This study included 581 patients. The mean age was 42 years, and 65% of patients were males. Only 50.9% declared a salary income and 38.5% had a health insurance. Half of the patients were homeless, and 80% were migrants. The main reasons to visit these health facilities were direct access (no appointment needed), being in financial difficulty and having a medical record in the same hospital. Half of the patients had one chronic disease at least, while only a third of them saw regularly a physician. A total of 834 diseases were found among the 581 patients, including 411 chronic diseases, and 17% of the patients had a psychologic or a psychiatric disorder. Prognosis was divided in three grades: good, low and poor. Almost a half of the patients were considered by the doctor as having a low or a poor prognosis if they would not receive a therapy.The findings of this study suggest that the PASS carry out their mission: most of the patients frequenting these facilities live under poor conditions and are in poor health status compared to the patients having access to conventional outpatient services.

This report describes the case of woman who was admitted to the hospital for highly destructive axial and peripheral arthropathy in association with acute malignant hypertension and skin purpura. Type I IgGkappa serum cryoglobulinemia was identified and was classified as a monoclonal gammopathy of unknown significance. Cryoglobulin was shown to crystallize in the serum and synovium fluid and was responsible for both granulomatous microcrystalline synovial inflammation and occlusive vasculopathy in the kidneys and skin. Cryocrystalglobulinemia pathogenicity and therapeutic implications are discussed.

Recessive X-linked myotubular myopathy has recently been shown to be linked to the mutation of a gene located in the Xq28 region. Evolution is used to be considered as fatal but mild forms or forms with a better prognosis have been recorded since. We report a case in a patient, whose parents were warned of fatal outcome once the diagnosis was made during the neonatal period. The reaction of the parents was to avoid any relationship with medical care. Ten years later the patient was seen in relatively good health thus proving that the evolution was more favourable than anticipated.

Objectives To investigate bone involvement in a large cohort of systemic mastocytosis (SM) patients, and evaluate the efficacy of bisphosphonate therapy. Patients and Methods From 2000 to 2004, 75 patients with SM according to WHO criteria underwent skeletal x-rays and bone mineral density (BMD) assessment. Sequential BMD assessments were performed in nine patients treated with bisphosphonate (mean follow-up 65 months). Results 37 patients (49%) had bone involvement according to both x-rays and BMD evaluations: osteoporosis (23 patients, 31%, mean lumbar spine T score: −3 SD), with vertebral fracture (13 patients, 17%), axial skeleton osteosclerosis (six patients, 8%), mixed patterns (three patients), osteopenia with pre-existing fractures (four patients) and focal osteolytic lesion (one patient). Blood count abnormalities were associated with osteosclerosis (p=0.005). In nine patients with osteoporosis and bisphosphonate therapy, mean lumbar spine BMD increased from 0.83 to 0.92 g/cm 2 (+11.1%; ie, +2.05% per year) without recurrence of vertebral fracture. Conclusion Half of adult patients with SM have bone involvement. Osteoporosis is the most prevalent bone manifestation in SM (31%). Bisphosphonate therapy seems efficient to improve lumbar spine BMD during SM-related osteoporosis. Spine x-ray and BMD should be performed in all SM patients to detect those who may benefit from anti-osteoporotic therapy.

Resume Chez un patient de soixante trois ans, une coccygodynie initialement isolee, puis compliquee d'un syndrome de la queue de cheval incomplet a pu etre rapportee a de volumineux kystes meninges perineuraux des racines sacrees. Le diagnostic evoque par le scanner et la resonance magnetique nucleaire a ete confirme par la saccoradiculographie. La sedation durable des douleurs a pu etre obtenue par des injections intradurales de corticoides. Les kystes arachnoidiens, souvent asymptomatiques, peuvent etre responsables de coccygodynies ou de syndromes de la queue de cheval incomplets. Le caractere paroxystique des manifestations, l'exacerbation en position debout, l'accalmie en decubitus et enfin le reveil par la percussion du sacrum permettent d'evoquer le diagnostic. Le traitement est avant tout medical, l'indication chirurgicale depend de la persistance, de l'intensite des douleurs et de l'existence de signes neurologiques deficitaires.

Introduction L’osteopathie hyper-trophiante (OHA) est un syndrome paraneoplasique rare associant des douleurs articulaires, osseuses et un hippocratisme digital s’integrant dans le cadre de pathologies broncho-pulmonaires. Observation Nous presentons le premier cas d’une patiente de 40 ans presentant une OHA associee a un carcinome vesiculaire differencie invasif de la thyroide revele par une masse de 4 cm du lobe droit opere en 2 temps. Ces 2 chirurgies sont suivies d’une totalisation isotopique puis, une recidive locale rapide invasive jugee inextirpable motive une radiotherapie cervicale. Un 2 e traitement par 100 mCi d’iode 131 confirme le caractere refractaire. Une reprise chirurgicale est tentee confirmant un cancer vesiculaire peu differencie pT4NxMx suivi de 12 cycles de chimiotherapie par GEMOX (gemcitabine-oxaliplatine). Durant 8 ans de suivi, la recidive cervicale est stable, emaillee d’episodes d’hemoptysies severes a repetition necessitant des embolisations iteratives des arteres bronchiques et tracheales. Un cancer bronchique est elimine. Un hippocratisme digital s’est installe, associe a une polyarthrite, des douleurs osseuses insomniantes et un syndrome inflammatoire sans secretion de thyroglobuline. Les radiologies et IRM des os longs retrouvent la presence d’appositions periostees. La scintigraphie osseuse confirme l’OHA. D’autres causes de polyarthrite ont ete eliminees. Elle a ete traitee par colchicine, AINS et corticotherapie mais seule l’association de Methotrexate et Plaquenil ® a permis de diminuer sa consommation de morphine. Discussion L’OHA est exceptionnellement associee a un cancer de la thyroide et souleve l’hypothese de la secretion d’un facteur circulant chez cette patiente presentant un cancer vesiculaire invasif recidivant, refractaire a l’iode.

Systemic mastocytosis is a rare disease, characterized by mast cells proliferation in various organs. Two types of clinical manifestations can be distinguished: those related to mast cells mediators release and those related to tumoral proliferation involving different organs, these later defining aggressive systemic mastocytosis. Until recently, treatment was mainly symptomatic, without anti tumoral effect.These last years, advances have been made in the understanding of the disease with the discovery of the c-kit oncogene mutation and the approach of the disease as a myeloproliferative disorder.Based on experiences acquired in the treatment of this kind of disorders, evaluation of new therapeutics, such as cladribine or combination of interferon-alpha and cytarabine is in progress. At least, tyrosine kinase inhibitors, a new family of molecules, are able of inhibiting some types of the mutated c-kit protein and one of them, imatinib mesylate, has shown a great efficacy in the treatment of gastro intestinal stromal tumors (GIST) which also involves the c-kit mutation. By analogy, treatment of patients with c-kit susceptible mutation might be treated with this molecule.

Recessive X-linked myotubular myopathy has recently been shown to be linked to the mutation of a gene located in the Xq28 region. Evolution is used to be considered as fatal but mild forms or forms with a better prognosis have been recorded since. We report a case in a patient, whose parents were warned of fatal outcome once the diagnosis was made during the neonatal period. The reaction of the parents was to avoid any relationship with medical care. Ten years later the patient was seen in relatively good health thus proving that the evolution was more favourable than anticipated.

Loperamide is an antidiarrheal peripheral opiate agonist, with rare neurological secondary effects. We report the case of a 26-month-old child who had impaired consciousness under treatment by loperamide, and was treated successfully with naloxone. Limitations of the use of loperamide in young children are underlined. Naloxone may be used in case of impaired consciousness, for a diagnostic as well as therapeutic purpose.

Perinatal asphyxia is a common emergency for both obstetricians and pediatricians. A prospective study was conducted in 14 maternity hospitals (type II centres) in the Paris suburbs in order to assess pediatric activity and neonatal morbidity associated with supposed perinatal asphyxia in term newborns. Pediatricians were called in at birth very frequently: 1/20 deliveries. Intubation and/or resuscitation procedures were needed in 20% of cases and 20% of infants were referred to a neonatal unit for birth asphyxia or associated pathology. Moderate encephalopathy was observed in 1.5% of all term newborns who needed medical intervention for supposed birth asphyxia.

In a series of 60 patients with Wegener's granulomatosis, 2 had initially presented with clinical signs suggestive of temporal arteritis. One of these two patients was a 69-year old woman suffering from inflammatory pain in the shoulders, wrists and knees, myalgias in the lower limbs and intermittent jaw claudication. The other patient was a 60-year old man with febrile polyarthritis predominantly affecting the knees and shoulders, and hyperaesthesia of the scalp. In both cases biopsy of the temporal artery gave negative results. Corticosteroids provided a dramatic improvement, but a relapse corrected the diagnosis. Three similar cases have been reported, but only one had a histological lesion of the temporal artery. Cases of temporal arteritis associated with pulmonary granulomatosis raise the problem of classification with localized Wegener's disease. An initial presentation suggestive of temporal arteritis may hide other systemic diseases, notably rheumatoid arthritis, periarteritis nodosa or Chug and Strauss angitis; Wegener's granulomatosis must be added to this list.

Resume Un homme de 65 ans est explore en raison de l'apparition de myalgies et d'un deficit de la force musculaire. Le dosage des creatine-phosphokinases est 35 fois superieur a la valeur normale. L'electromyogramme est de type myogene diffus. La biopsie musculaire montre l'association de lesions necrotiques des fibres musculaires et d'un infiltrat mononuclee a disposition perivasculaire, faisant porter le diagnostic de polymyosite. Ce patient etait traite par fenofibrate depuis 10 ans en raison d'une hyperlipidemie. La posologie quotidienne etait de 600 milligrammes depuis 32 mois. Huit jours apres l'arret du fenofibrate, les anomalies cliniques et biologiques disparaissent. Une epreuve de reintroduction pratiquee 6 semaines plus tard provoque rapidement une ascension des creatine-phosphokinases a 43 fois la valeur normale. L'arret du fenofibrate entraine une guerison rapide et definitive. Le fenofibrate doit etre ajoute a la liste des drogues responsables de polymyosite iatrogene.

Aortic arch dissection may be sometimes misdiagnosed due to the lack of mild to moderate chest pain. Definite diagnosis is often made while dissection has already occurred more than 15 days ago, being thereafter considered as chronic. Aortic dissection may then present as a prolonged febrile illness with fever and/or inflammation as main symptoms, with little or no pain.We retrospectively reviewed cases of chronic aortic dissections seen in a department of internal medicine and a department of neurology between 1975 and 1992.We report six cases of patients presenting with aortic dissection and describe their outcome and treatments after the diagnosis was made based on either thoracic computerized tomography or trans-esophageal echocardiography evidence. Four patients had surgical aortic arch repair while one patient was treated with beta-blockers.Chronic aortic dissection has rarely been reported to cause fever or increased sedimentation rate. Treatment has to be discussed between medical and surgical teams involved in the therapeutical management of these unusual patients.

To analyze the evolutive profile of sarcoidosis together with reciprocal interactions between pregnancy and sarcoidosis.All events that occurred during pregnancy in 11 women presenting with sarcoidosis were analyzed. Histological confirmation was obtained for the 11 cases. For all pregnancies were analyzed the course of both sarcoidosis and pregnancy, and the influence of pregnancy on the disease evolution.Among 33 pregnancies, 23 led to the birth of healthy fetuses (five spontaneous abortions, four voluntary abortions, and one therapeutic abortion). The major event was fetal hypotrophy in six cases. Three of them occurred during pregnancy in prednisone-treated patients with active sarcoidosis. No relapse of cured sarcoidosis or further evolution of sarcoidosis that was inactivated as of the beginning of pregnancy were observed. The course of active sarcoidosis varied, as improvement (one case), worsening (two cases) and stabilization (two cases) were observed. During the first year of follow-up after delivery, four relapses and, in two cases, preliminary signs of the disease were observed.Apart from the hypothetical but not definite risk of hypotrophy, no negative interaction between sarcoidosis and pregnancy could be established. Pregnancy does not seem to interfere with the course of sarcoidosis. Considering the risk of relapse after delivery, pregnant women presenting with sarcoidosis should benefit from clinical and radiological follow-up.

Pleuropulmonary manifestations of systemic vasculitis are common, polymorphic and of ambiguous significance: the same pulmonary lesion may reveal a specific manifestation of vasculitis as well as a therapy-induced complication, especially infection which may favor per se a flare-up. Two questions will be successively studied: what are the pleuropulmonary characteristics of Wegener's granulomatosis, Churg-Strauss syndrome, periarteritis nodosa, Behçet's disease, Takayasu's disease and temporal arteritis? What are the major adverse effects that may occur in the course of a treated systemic vasculitis?

Since the first suggestion of heparin-induced osteoporosis in 1963, a large body of work has been published. The mechanism can be explained by the effect of heparin as a cofactor for physiological stimulators of osteoclasts. Low-molecular weight heparins are an interesting alternative to non-fractionate heparin as the risk is reduced with an equivalent anticoagulation activity. Prevention is based on screening for patients at risk, preferential use of low-molecular weight heparins, early switch to anti-vitamin K and vitamin and calcium supplementation in pregnant women an elderly subjects. Curative treatment combines vitamin-calcium supplementation with inhibitors of bone resorption.

Loperamide is an antidiarrheal peripheral opiate agonist, with rare neurological secondary effects. We report the case of a 26-month-old child who had impaired consciousness under treatment by loperamide, and was treated successfully with naloxone. Limitations of the use of loperamide in young children are underlined. Naloxone may be used in case of impaired consciousness, for a diagnostic as well as therapeutic purpose.

Intravesical administration of Calmette-Guérin bacillus (BCG) is effective in the treatment of superficial bladder carcinoma. Transient arthritis or migratory arthralgia has been reported in 0.5% of cases. The authors report on four men (mean age 65 years), who developed an oligoarthritis in three cases after the 2nd, 5th, and 6th weekly instillation of Pasteur BCG, respectively, and symmetrical polyarthritis in one after 48 BCG instillations over a three-year period. Joints involved were the knees (3/4), ankles (3/4), shoulders (1/4), wrists, and hands (1/4). Features included morning stiffness and local evidence of inflammation. All four patients had an elevated erythrocyte sedimentation rate and negative tests for rheumatoid factor. Neutrophils were the main cell type in synovial fluid. Synovial biopsy performed in two cases revealed non-specific inflammation. Erosions of the metatarsophalangeal joints were observed in one patient. Locoregional or systemic symptoms included transient fever (3/4), cystitis (4/4), urethritis (1/4), epididymoorchitis (2/4), conjunctivitis (1/4), and pleural effusion with pericarditis (1/4). The BCG was recovered from an epididymal specimen in one patient. Two patients were positive for the HLA B27 antigen. Outcome was favorable in every case (range: 15 days-6 months) after discontinuation of BCG therapy and administration of isoniazid, rifampin, and prednisone (3 patients) or NSAID (1 patient). Various pathogenic hypotheses for BCG-induced arthritis are discussed, including infection, immune responses to heat shock proteins, and reactive arthritis.

There are very few drugs effective in the treatment of diffuse scleroderma and therefore we conducted an open study with gamma interferon. Among 20 diffuse scleroderma, evolving since less than 3 years, an improvement was observed in 8 patients. There was no serious side effect. Survival of these 20 patients was 85% at 5 years.

Bone mastocytosis is characterized radiographically in some patients by diffuse osteosclerosis and in others by demineralization. The reason for these apparently conflicting bone features is unknown. Bone remodeling and marrow mastocytosis infiltration were studied in nine cases of mastocytosis with bone marrow involvement. Six men, ranging from 42 to 78 years of age, and three women, 43, 55, and 73 years old, comprised the series. Two patients had severe and diffuse osteosclerosis. Seven had diffuse demineralization, with crushed vertebrae in four, suggesting common osteoporosis. In three of the seven, cutaneous mastocytosis was absent. Bone biopsies were undecalcified and stained with toluidine blue. In the seven patients with demineralization, the number of marrow mastocytes was increased (154 +/- 24 versus 2 +/- 0.5/mm2 in normal postmenopausal osteoporosis). Mastocyte nodules covering 1-9% of the marrow area were present in all seven patients. These patients showed a significant increase in remodeling; bone formation rate was increased, coupled with a decrease in mean wall thickness. Concomitantly, osteoclast surfaces were increased, with an increased amount of bone resorbed. The two patients with diffuse osteosclerosis had a markedly different histology; mast cell infiltration was dramatically increased (mastocyte count greater than 1000/mm2) with diffuse marrow fibrosis. Bone volume was increased as well, and most of the bone was woven with an intratrabecular mineralization defect. High bone remodeling and decreased osteoblast activity can explain bone loss in mastocytosis with demineralization. Mastocytosis with osteosclerosis is characterized by a more extensive marrow mast-cell infiltration and fibrosis.

Cardiac complications are exceptional in long-term chloroquine therapy; congestive heart failure and restrictive cardiomyopathy may develop, but disorders of conduction are more frequent. The characteristics of these disorders emerge from 12 cases in the literature and from 2 personal cases. The usual disorder is fascicular block which may become a complete, syncopal, atrioventricular block, as in one of our 2 patients. The time elapsed between the beginning of treatment and the occurrence of these disorders (2 to 30 years) and the total dose of chloroquine received (100 to 2,500 g) are extremely variable. Retinopathy or neuromyopathy is present in 64 and 35 percent of the cases respectively. The diagnosis is confirmed by endomyocardial biopsy with electron microscopic study which shows vaculoar myopathy with numerous large secondary lysosomes containing a dense material of lamellar structure (myelinic figures, curvilinear bodies). Regression of heart conduction disorders after withdrawal of chloroquine seems to be inconstant and incomplete. The rare occurrence of this complication raises the question of genetic predisposition. We believe that chloroquine therapy should be contra-indicated in patients with a history of conduction disorders and that a 6-monthly electrocardiographic control of these patients would be justified.

In a series of 60 patients with Wegener's granulomatosis, 2 had initially presented with clinical signs suggestive of temporal arteritis. One of these two patients was a 69-year old woman suffering from inflammatory pain in the shoulders, wrists and knees, myalgias in the lower limbs and intermittent jaw claudication. The other patient was a 60-year old man with febrile polyarthritis predominantly affecting the knees and shoulders, and hyperaesthesia of the scalp. In both cases biopsy of the temporal artery gave negative results. Corticosteroids provided a dramatic improvement, but a relapse corrected the diagnosis. Three similar cases have been reported, but only one had a histological lesion of the temporal artery. Cases of temporal arteritis associated with pulmonary granulomatosis raise the problem of classification with localized Wegener's disease. An initial presentation suggestive of temporal arteritis may hide other systemic diseases, notably rheumatoid arthritis, periarteritis nodosa or Chug and Strauss angitis; Wegener's granulomatosis must be added to this list.

In a 65-year old man complaining of myalgias and loss of muscular strength, the creatine phosphokinase level was found to be 35 times higher than normal values. The electromyogram was of the diffuse myogenic type. Muscle biopsy showed necrotic lesions of the muscle fibres associated with perivascular infiltrates of mononuclear cells, leading to the diagnosis of polymyositis. This patient had been treated for 10 years with fenofibrate for hyperlipidaemia; during the last 32 months he had taken this drug in doses of 600 mg per day. Eight days after fenofibrate was discontinued, all clinical and laboratory abnormalities had disappeared. A reintroduction test performed 6 weeks later raised the creatine phosphokinase level up to 43 times the normal value. Withdrawal of fenofibrate therapy resulted in rapid and lasting recovery. This case shows that fenofibrate should be added to the list of drugs that are responsible for iatrogenic polymyositis.

In a 63-year old male patient coccygodynia, initially isolated then complicated by incomplete cauda equina syndrome, could be attributed to large perineurel meningeal cysts on the sacral nerve roots. The diagnosis was suspected at computerized tomography and nuclear magnetic resonance and confirmed by sacculoradiculography. Intradural injections of corticosteroids provided lasting pain relief. Arachnoid cysts are often asymptomatic, by they may be responsible for coccygodynia and/or incomplete cauda equina syndrome. Their presence is suggested by the characteristics of the symptoms which are paroxysmal, exacerbated in standing position, relieved in dorsal position and revived by percussing the sacrum. Treatment is medical in most cases. The decision to operate depends on the persistence and intensity of pain and on whether signs of neurological defecit are present.

Nine cases of infective endocarditis (IE) on native valves, complicated by arterial embolism of the limbs (AEL), were collected between June 1974 and October 1988 (prevalence 4.3 percent). Among the 11 AEL recorded, 9 involved the lower limbs and 2 the upper limbs. The diagnosis, suspected in patients with acute ischaemia (n = 6), transient (n = 1) or pseudophlebitic (n = 1) pain, or discovered by systematic pulse examination (n = 3), was confirmed by Doppler ultrasound (n = 3), angiography (n = 2) or oscillometry (n = 4). AEL occurred 2.8 weeks on average after the onset of treatment; it appeared 6 months after the end of treatment in 1 case and preceded the diagnosis of IE by 1 to 6 weeks in 3 cases. The causative organisms isolated in 7 cases were: non-haemolytic streptococci (n = 4), Staphylococcus aureus (n = 1), Haemophilus parainfluenzae (n = 1) and enterococcus (n = 1). Vegetations were found in 6 of the 7 patients explored by echocardiography. Two cases of embolism of the femoral artery required embolectomy. Effective heparin anticoagulation was obtained in only one patient. Six patients underwent valve replacement in the acute phase of endocarditis. After a mean follow-up period of 32 months (range 3 to 120 months), only one patient has symptoms (claudication of the left upper limb); 5 patients are asymptomatic with a reduced (n = 5) or abolished (n = 2) pulse. Three embolisms have left no sequelae. Altogether, AEL are not uncommon in infective endocarditis. They rarely influence the functional prognosis and are detected by systematic palpation of the pulses. Anticoagulation in effective doses is discussed. Attempts at removing the obstruction should be made only in cases with poorly tolerated proximal embolism. In patients with multiple or recurrent embolic accidents, valve replacement may be considered.

The authors report a case of non-hodgkin's lymphoma initially presenting with pallakiuria due to a prostatic localization of the tumour. The diagnosis was confirmed 6 months later following deterioration in the general condition with lymphomatous meningitis, after repeat examination of the prostatic slides. Less than twenty cases of prostatic lesions revealing lymphoma have been reported in the literature. There are no formal diagnostic arguments apart from the histology which is often difficult to interpret. In most cases the lymphomas are disseminated and composed of large cells or cleaved small cells with a poor prognosis and a mean survival of 14 months. Treatment primarily consists of chemotherapy, as the lymphoma is always disseminated. The role of local radiotherapy is questionable.