Plaie cardiaque auto-infligée : il l'a « cloué »

IntroductionNail guns are responsible for an estimated 14% of injuries among residential carpenters, intrathoracic injuries are rare but almost always require operative management with a sternotomy or thoracotomy.Case reportWe report the case of a young carpenter who injured himself by accident during work. The nail perforated the right ventricle. He was operated and postoperative course was uneventful.ConclusionThis case highlights the importance of urgent and adequate management of these cases and the need to raise awareness about work safety among carpenters.     

Les « NACs » : un risque allergique nouveau ?

In recent years, to the list of classic pet animals (dogs and cats) as allergens we must now add the New Pet Animals (NPAs). This group of animals, referred to by the Anglo-Saxons as pets, includes both those previously recognized (rabbit, guinea pig, hamster, birds) and the “truly new NPAs”; by general agreement “NPA” will include all animals other than cats and dogs. Some rather rare animals are regularly added to this list. The emergence of “NPAs” can be related to a social phenomenon, in particular, fashion and the need for the exotic. They are a very diverse group: warm-blooded animals, spiders, batrachia (frogs, toads, salamanders, etc.) and reptiles. Besides the physical risks from their natural aggressive behaviour, the “NPAs” can be an allergic risk factor and this risk has a tendency to increase. Allergists and paediatricians have a role to play in the diagnosis and prevention of these allergies by giving advice on the choice of pet animals. This review concerns allergies to rodents, reptiles, batrachians, spiders, etc.     

Dysregulation of circulating CD4 + CXCR5 + PD-1+ T cells in diabetic retinopathy

AimsWe aimed to determine an association between follicular helper T (Tfh) cells and Bcl-6 and CXCL13 levels and determine the role of Tfh cells, Bcl-6, and CXCL13 serum levels in the pathogenesis of diabetic retinopathy (DR) since Tfh cells have an important role in type 1 diabetes; however, their role in type 2 diabetes-related DR requires exploration.MethodsBlood samples were collected from 24 patients with non-proliferative diabetic retinopathy (NPDR), 20 with proliferative diabetic retinopathy (PDR), and 18 age- and sex-matched healthy volunteers. Flow cytometry detected CD4 + CXCR5 + PD1+ Tfh cells. Serum Bcl-6 and CXCL13 levels were determined using enzyme-linked immunosorbent assay.ResultsCD4 + CXCR5 + PD-1+ Tfh cell percentages in peripheral blood and serum levels of Bcl-6 and CXCL13 in the non-proliferative DR (NPDR) and proliferative DR (PDR) groups' were significantly higher than those in healthy individuals. The proportion of Tfh cells in DR patients' peripheral blood positively correlated with Bcl-6 and CXCL13 serum levels, DR course severity, Fasting blood glucose, glycosylated hemoglobin and body mass index.ConclusionsThe increased circulating Tfh cells, serum Bcl-6 levels, and CXCL13 levels of DR patients with type 2 diabetes suggested that circulating Tfh cells and the germinal center response may have a role in the occurrence and development of DR.     

Asthma between 2 and 5 years: a key period

The preschool asthmatic child is at the crossroads between virus induced airway obstruction and allergy-based asthma. There are no diagnostic tests other than a careful history and if possible prospective observation. Allergy tests are helpful and may guide the required treatment. Pharmacotherapy is the mainstay but may be supplemented by allergen-specific immunotherapy. Unfortunately inhaled corticosteroids (ICS) do not seem to lead to improved symptom-free periods once this treatment is stopped. In the allergy-driven asthmatic long-term treatment strategies must be envisaged.     

La syphilis au CHU de Nantes entre 2000 et 2010 : à propos de 36 patients hospitalisés

Purpose

Syphilis infection increase has been observed since the early 2000s. The medical records of patients hospitalized for syphilis at the tertiary care hospital of Nantes between 2000 and 2010 were retrospectively reviewed.

Methods

Cases were selected on the basis of serological database of the laboratory of bacteriology and extraction from the PMIS. Syphilis cases were defined by both positive TPHA and VDRL tests.

Results

The number of positive serology testing was increased eightfold within ten years. Among the 36 patients with syphilis hospitalized cases, 97% were male, aged 17 to 75 years. Eighteen were HIV-infected patients. Among them, 94% were homosexuals and 67% had a history of sexually transmitted infections. The mean time between symptoms and diagnosis was significantly higher in non HIV-infected patients. Clinical forms of syphilis were cutaneomucous secondary syphilis with frequent systemic symptoms for 33%, neurosyphilis, including frequent uveitis for 50%, and gummatous tertiary syphilis involving bones for one patient. Secondary syphilis cases were treated with one to three doses of benzathine penicillin G. Late syphilis and cases of neurosyphilis were treated with penicillin G or ceftriaxone. Neurosensory sequelae accounted for 39% neurosyphilis cases.

Conclusion

This study highlights the incidence increase of syphilis cases in France, frequent poor prognosis of neurosyphilis cases, and diagnosis difficulties, particularly in non HIV-infected patients. This emphasizes the broader use of syphilis serology for compatible medical situations.     

Thrombopénie immunoallergique à la rifampicine : à propos d'un cas

Rifampicin can induce toxic and hypersensitivity reactions. However, immediate hypersensitivity (IgE-mediated) reactions are rare. In contrast, other types of reactions, among which are the immunoallergic thrombocytopenias, are not exceptional. We report the case of a 73 year-old man with pleural tuberculosis who reported having hemorrhagic and purpuric symptoms five hours after beginning treatment with rifampicin, isoniazid and pyrazinamide. A diagnosis of rifampicin-induced immunoallergic thrombocytopenia was made, based on extrinsic and intrinsic etiological criteria, despite a negative specific serum antibody assay and a borderline positive rifampicin skin prick test. No previous treatment with rifampicin was reported by the patient, except for prior prolonged self-administration of eye drops that may have contained rifampicin. This adverse effect cannot be explained by an immediate type hypersensitivity reaction, but probably resulted from a type II or III hypersensitivity reaction, as suggested in the literature. The short interval between the beginning of treatment and the onset of symptoms may have been a consequence of earlier sensitization to rifampicin-containing ophthalmic drops. In conclusion, we report a case of rifampicin-induced immunoallergic thrombocytopenia. This case illustrates the limits of diagnostic tests for drug allergy, especially for type II and III hypersensitivity reactions. It also raises the question of the sensitizing potential of drugs administered locally, as well as the question of the necessity of informing physicians and patients of this possibility.     

« Anticorps anti-TNF,quelles applications,quels effets secondaires ? »

TNF-α is a pivotal cytokine with pleiotropic effects in the innate and adaptive immune systems. Clinically, two strategies have been developed to neutralize it: monoclonal anti-TNF-α antibodies and a recombinant protein containing the p75 receptor. These products have been shown to be remarkably efficacious in the treatment of certain autoimmune and inflammatory conditions, in particular, in rheumatoid arthritis, spondyloarthropathies and psoriasis, and the monoclonal antibody in Crohn's disease; this list of diseases is constantly growing. Inhibitors of TNF-α are generally well tolerated, but there is still a lack of data on their long-term tolerance, for example, concerning lymphoproliferative syndromes. Most of the studies have revealed an increase in the susceptibility to certain infections, in particular, intracellular pathogens such as Mycobacterium tuberculosis. It is now clear that TNF-α inhibitors are not equivalent with respect to both their therapeutic efficacy and their adverse effects. Better appreciation of the mechanisms responsible for these differences is an important challenge, not only to sharpen their therapeutic indications but also to begin new research programs aimed at the development of new generations of biotherapies that are more efficacious and better tolerated than those presently available.     

Alzheimer's disease – Germany

To illustrate the up-to-date pattern of patient management and adherence to common clinical guidelines in daily practice in Germany, a standardised example of an outpatient with reasonable suspicion to dementia was evaluated according to personal experience and published evidence from original studies and national guidelines regarding standard diagnostic procedures, the role and diagnostic steps of the family physician (FP), the access to a specialists treatment, perceptions on dementia in the lay public, drug treatment habits and the role of Alzheimer's associations. In Germany, FPs are generally the first to be approached in the case of emerging cognitive deficits. Their standard diagnostic procedures usually comprise a physical examination including a short psychiatric and neurological examination, blood laboratory tests and the assessment of history from relatives or caregivers. The specialists in private practice in the field of neuropsychiatry evaluate a demented subject in more detail after referral from FPs. Diagnostic evaluation frequently includes tests and rating scales, and also neuroimging of the brain by CT or MRI. Acetylcholinesterase inhibitors (AChE-I) and memantine, several nootropics and Ginkgo biloba are readily available and are all reimbursed by health insurances, if used according to their indication. Due to an increasing awareness of dementia within the lay public, Alzheimer's associations are active in Germany on a national and a regional level. In Germany, dementia is increasingly accepted as a medical condition among FPs and the lay public. Despite this increasing awareness, diagnostic and therapeutic practice is frequently not following current evidence-based guidelines and general management patterns of dementia should be more consistent and comprehensive.