Disseminated tuberculosis after anti-TNF alpha treatment: Do not blindly trust the IGRA test.

INTRODUCTION: Interferon gamma release assay (IGRA) is used to detect latent tuberculosis prior to biological treatments in the context of suspected inflammatory rheumatism. METHODS: We report the case of a 50-year-old woman with negative IGRA test before adalimumab introduction for presumed axial spondyloarthritis. RESULTS: The worsening of symptoms under treatment led to further investigations and the diagnostic of disseminated tuberculosis (TB) was later established with miliary and multiple bone locations such as spondylitis and sacroilitis. The patient's history revealed past exposure to tuberculosis. This observation illustrates the limitations of IGRA in such situation due to its variable performance for active TB diagnosis. CONCLUSION: Misdiagnosis is frequent in bone tuberculosis due to non-specific signs. We draw the attention to the importance of a global risk assessment prior to the introduction of biological treatment for suspected chronic inflammatory rheumatism and recall the risk factors for false-negative IGRA. An extended treatment course may be necessary after exposure to anti-TNF-alpha.

Disseminated tuberculosis after anti-TNF alpha treatment: Do not blindly trust the IGRA test / Tuberculosis diseminada tras tratamiento anti-TNF alfa: no confíe ciegamente en la prueba IGRA

Introduction: Interferon gamma release assay (IGRA) is used to detect latent tuberculosis prior to biological treatments in the context of suspected inflammatory rheumatism. Methods: We report the case of a 50-year-old woman with negative IGRA test before adalimumab introduction for presumed axial spondyloarthritis. Results: The worsening of symptoms under treatment led to further investigations and the diagnostic of disseminated tuberculosis (TB) was later established with miliary and multiple bone locations such as spondylitis and sacroilitis. The patient's history revealed past exposure to tuberculosis. This observation illustrates the limitations of IGRA in such situation due to its variable performance for active TB diagnosis. Conclusion: Misdiagnosis is frequent in bone tuberculosis due to non-specific signs. We draw the attention to the importance of a global risk assessment prior to the introduction of biological treatment for suspected chronic inflammatory rheumatism and recall the risk factors for false-negative IGRA. An extended treatment course may be necessary after exposure to anti-TNF-alpha.(AU)

Introducción: El ensayo de liberación de interferón gamma (IGRA) se utiliza para detectar tuberculosis latente antes de los tratamientos biológicos en el contexto de sospecha de reumatismo inflamatorio. Métodos: Presentamos el caso de una mujer de 50 años con IGRA negativo antes de la introducción de adalimumab por presunta espondiloartritis axial. Resultados: El empeoramiento de los síntomas bajo tratamiento llevó a nuevas investigaciones y posteriormente se estableció el diagnóstico de tuberculosis (TB) diseminada con localizaciones pulmonar y óseas múltiples como espondilitis y sacroilitis. La historia de la paciente reveló una exposición pasada a la TB. Esta observación ilustra las limitaciones del IGRA en tal situación debido a su rendimiento variable para el diagnóstico de la TB activa. Conclusiones: El diagnóstico erróneo es frecuente en la TB ósea debido a signos inespecíficos. Llamamos la atención sobre la importancia de una evaluación de riesgo global antes de la introducción de un tratamiento biológico para la sospecha de reumatismo inflamatorio crónico, y recordamos los factores de riesgo para falsos negativos del IGRA. Puede ser necesario un curso de tratamiento prolongado después de la exposición al tratamiento anti-TNF-alfa.(AU)

[Endobronchial metastases of rectal adenocarcinoma]. / Métastases endobronchiques d'un adénocarcinome rectal.

INTRODUCTION: Diagnosis of endobronchial metastases is facilitated by immunolabeling techniques on bronchial biopsy samples. CASE: Endobronchial tumors appeared in a 70-year-old woman with an adenocarcinoma of the crypts of Lieberkuhn, diagnosed two years previously. Immunohistochemical examinations made it possible to diagnose endobronchial metastases of the rectal adenocarcinoma. COMMENTS: The endobronchial zone is a relatively rare metastatic site. Metastases associated with rectal adenocarcinoma account for 11-26% of secondary endobronchial lesions. After endoscopic biopsy, immunolabeling techniques help to differentiate between primary adenocarcinoma and endobronchial metastasis. Prognosis is poor.

[Accelerated atheroma with prednisone and clopidogrel]. / Athérome accéléré lors d'un traitement par prednisone et clopidogrel.

INTRODUCTION: Several mechanisms may explain the aggravation of atheroma lesions in patients receiving corticosteroid treatments. CASE: This 68-year-old man, a smoker with high cholesterol levels and a history of two transient ischemic attacks, also had severe Horton disease (giant cell arteritis) requiring treatment by corticosteroids and azathioprine. After a new transient ischemic accident, clopidogrel treatment was initiated. Ten months later, severe carotid stenosis was observed. Endarterectomy removed a recent thrombus and the pathology examination showed necrotic lesions complicated by hemorrhage with inflammatory infiltrate. DISCUSSIONS: This patient's atheromatous disease was aggravated by intraplaque hemorrhage, caused by several factors include his corticosteroid therapy and platelet aggregation inhibition treatment.

Acute meningitis owing to phlebotomus fever Toscana virus imported to France.

Acute lymphocytic meningitis, seen in France in summer, is often due to enteroviruses. Arboviruses as West Nile and tick-borne encephalitis do exist in Europe, but other viruses are rarely considered in patients unless they have had recent tropical travel. Toscana virus infection, which is endemic, especially in Italy,1-3 has been documented in some European travelers returning from Italy,4-6 but surprisingly was not documented in France until recently.7 We report a case of meningitis caused by Toscana virus imported to France.

[Rofecoxib-related cutaneous vasculitis]. / Vascularite cutanée liée au rofécoxib.

INTRODUCTION: Drugs are at the origin of around 10% of the cases of vasculitis involving the small vessels. Recent cases report vasculitis related to the administration of nonsteroidal antiinflammatory selective inhibitors of cyclo-oxygenase 2. CASE: Vasculitis associated with ketoprofen appeared in a 76 year-old man: the symptoms disappeared when treatment stopped. A few weeks later, during treatment with rofecoxib, a relapse appeared, including purpura. The diagnosis of rofecoxib-induced cutaneous vasculitis was confirmed by regression of all symptoms when treatment stopped. DISCUSSION: Coxibs, like other nonsteroidal antiinflammatory drugs, may cause vasculitis, at an as-yet undetermined frequency.

[Langerhans cell histiocytosis in an adult patient associated with sclerosing cholangitis and cerebellar atrophy]. / Histiocytose langerhansienne de l'adulte avec cholangite sclérosante et atrophie cérébelleuse.

Langerhans' cell histiocytosis is a disorder in children or young adults, characterized by clonal proliferation of histiocytic cells, staining for CD1a, with uni or multifocal organ involvement. It's a rare condition in adults. We report a case of Langerhans' cell histiocytosis in an adult with sclerosing cholangitis which rapidly progressed to fatal liver failure and progressive cerebellar atrophy. Langerhans cell histiocytosis is a rare cause of sclerosing cholangititis in adults.

[Right diverticular colitis revealing an Ehlers-Danlos syndrome]. / Colite diverticulaire droite révélatrice d'un syndrome d'Ehlers-Danlos.

INTRODUCTION: Colic diverticulosis rarely occurs in the young and, in such cases, therefore requires search for a predisposing affection. OBSERVATION: A 25 year-old woman was hospitalised for abdominal pain and fever predominating in the right iliac fossa and leading to the diagnosis of right diverticular colitis. The clinical examination revealed features suggestive of an Ehlers-Danlos syndrome. DISCUSSION: The Ehlers-Danlos syndrome combines cutaneous sensitivity and articular hypermobility related to abnormality in the supporting connective tissue. Colic diverticulosis is found among the complications. Diverticular colitis occurring in a young adult should lead to the search for an originating disease of the connective tissue.

[Upper mesenteric venous thrombosis revealing familial resistance to activated protein C]. / Thrombose veineuse mésentérique supérieure révélant une résistance à la protéine C activée familiale.

INTRODUCTION: Mesenteric venous thrombosis is a rare disease but potentially severe because of the prognosis of intestinal infarction with high mortality rate (60%). OBSERVATION: We report the case of a 55 year-old man who presented with an upper mesenteric venous thrombosis related to a familial resistance to C reactive protein through factor V Leiden mutation. COMMENTS: The discovery of a mesenteric venous thrombosis requires aetiological research that is usually multifactorial. Among the most frequent genetic coagulation abnormalities observed resistance to C reactive protein due to G202110A prothrombin gene mutation is the most common. Although factor V Leiden mutation is less frequent, it requires anticoagulation therapy for life in the case of the appearance of a thrombosis.