Investigation of fluoroquinolone-induced myalgia using (31)P magnetic resonance spectroscopy and in vitro contracture tests.

OBJECTIVE: To investigate muscle function in patients with severe myalgia resulting from fluoroquinolone (FQ) treatment. We used histology, in vitro contracture tests (IVCTs), and (31)P magnetic resonance spectroscopy ((31)P MRS) to explore muscle contraction and metabolism. METHODS: We studied 3 patients with myalgia, hyperalgia tendinopathy, and arthralgia following FQ treatment and 3 normal subjects after taking FQs. Results were compared with those of a control group of 9 subjects free of any muscle disease and not taking FQs. Muscle biopsies were performed on the left biceps, and IVCTs were performed in accordance with the protocol recommended by the European Malignant Hyperthermia Group. (31)P MR spectra of forearm flexor muscles were recorded at 4.7T throughout a rest-exercise-recovery protocol. RESULTS: (31)P MRS showed a significant reduction of pH changes measured at the end of exercise and a faster rate of proton efflux measured during recovery in all patients. IVCTs diagnosed 1 patient as being susceptible to malignant hyperthermia. No specific histologic anomalies were observed in muscle biopsy samples, which showed normal mitochondria. CONCLUSION: The adverse effects recorded in the 3 patients are related to a preexisting muscular anomaly revealed by FQ treatment.

Malignant hyperthermia susceptibility revealed by myalgia and rhabdomyolysis during fluoroquinolone treatment.

Fluoroquinolones cause myalgia, but this complication is not clearly documented. We describe a patient who developed myalgia and rhabdomyolysis during fluoroquinolone treatment. The patient was a 33-year-old man treated with norfloxacin for common cystitis. He complained of general muscular fatigue, tendon disorders, and articular pain during treatment. When the antimicrobial agent was stopped, symptoms decreased, with persistence of slight myalgia for 10 days. Rhabdomyolysis was detected. Six months later, investigation by 31P magnetic resonance spectroscopy revealed an oxidative disorder and an abnormal abundance of phosphomonoesters. In vitro contracture tests led to a diagnosis of malignant hyperthermia susceptibility. Our case shows that for any subject presenting myalgia with rhabdomyolysis triggered by fluoroquinolone treatment, the presence of a latent myopathy should be investigated.

Cannabis arteritis revisited--ten new case reports.

The purpose of this paper was to revisit the old concept of cannabis arteritis first described in the 1960s and report 10 new cases. Ten male patients, with a median age of 23.7 years developed subacute distal ischemia of lower or upper limbs, leading to necrosis in the toes and/or fingers and sometimes to distal limb gangrene. Two of the patients also presented with venous thrombosis and three patients were suffering from a recent Raynaud's phenomenon. Biological test results did not show evidence of the classical vascular risk factors for thrombosis. Arteriographic evaluation in all cases revealed distal abnormalities in the arteries of feet, legs, forearms, and hands resembling those of Buerger's disease. A collateral circulation sometimes with opacification of the vasa nervorum was noted. In some cases, arterial proximal atherosclerotic lesions and venous thrombosis were observed. All patients were moderate tobacco smokers and regular cannabis users. Despite treatment with ilomedine and heparin in all cases, five amputations were necessary in four patients. The vasoconstrictor effect of cannabis on the vascular system has been known for a long time. It has been shown that delta-8- and delta-9-tetrahydrocanabinols may induce peripheral vasoconstrictor activity. Cannabis arteritis resembles Buerger's disease, but patients were moderate tobacco smokers and regular cannabis users. These cases show that prolonged use of cannabis could be an additive risk factor for juvenile and young adult arteritis. Cannabis arteritis is a forgotten and severe occlusive vascular disease occurring in young adults. Search for cannabis use may be an important tool for a better knowledge of arteritis in young smokers.

[Lead poisoning in adults. Experience of the Poison Control Center of Marseille from 1993 to 2000]. / Le saturnisme des adultes. Expérience du Centre antipoison de Marseille de 1993 à 2000.

OBJECTIVE: Report the experience of the Marseille's anti-poison center with lead poisoning adults. PATIENTS AND METHODS: Between 1993 and 2000, 45 adults patients consulted the poison Centre of Marseille for a history of lead exposure (9 women, 36 men, average age 44 YO, between 22 an 76 YO). The lead sources were mostly occupational (welding, heavy metal industries...), but some were environmental (shooting as a hobby, hunting,...). RESULTS: Ninety-one percent of the patients presented with a clinical feature of possible lead intoxication (asthenia, abdominal pain, anaemia, seizures,...). For 22 patients, calcitetracemate provocation test was negative. 6 patients with a positive test refused to be treated. 16 patients with a positive test were treated with chelation therapy (average lead blood level 566 micrograms/l--mini 320 micrograms/l, maxi 943 micrograms/l--and average lead urine elimination 3,011 micrograms/24 H--mini 789 micrograms/24 H, maxi 7,229 micrograms/24 H. 58 cures were done (1 to 12 cures for each patient). The average quantities of lead eliminated in the urine during the chelation therapy was 30,912 micrograms +/- 29,059 micrograms by case. For 12 patients who stopped the lead exposure after the diagnosis of lead poisoning, the chelaion therapy permitted to decrease the lead blood level of 69%. For 4 patients still exposed during the treatment, the lead blood level decrease of 7% only. For the 16 treated patiEnts, a clinical improvement was noted, and no adverse effects of chelation therapy was observed during the 58 cures.

[Impact of delta-9-tetrahydrocannabinol and its metabolites on the immune system]. / Impact du delta-9-tetrahydrocannabinol et ses métabolites sur le système immunitaire.

Many studies obvious impact of cannabinoids on the immune system. These studies follow the rapid advanced researches led in the immunology field. D9 Tetrahydrocannabinol and their metabolites decrease production of tumoral necrosis factor alpha. This decrease has for consequence a decrease of the apoptosis. Recent discovery of implication of cytokines in the phenomena of dependence, make the cannabis and their metabolites promoting agent induced dependence in association with drug abuse. The withdrawal of these products necessitates a intact immune system. D9 Tetrahydrocannabinnol and their metabolites inhibit production of IL-1 and gamma interferon. This inhibition has for consequence a decrease of 33% of the lymphocytes activity and an inhibition of 66% of the lymphocytes adenyl cyclase activity. The consumption of cannabis decreases immunological competence of macrophages, and alterate their essential role of trophicity of the nervous central system. Furthermore, inhibiting actions of cannabinoids on the cyclo-oxygenase, promote production of arachidonic acid degradation products. This compounds mimic the action of histamine, and inducing a raise of the vascular permeability and bronchospasm. These inolecules contributes at delayed reaction of anaphylaxia. However these actions of cannabinoids on the immune system promote their pull-back in cure of new pathology likes AIDS.

[Methamidophos intoxication: immediate and late neurological toxicity; two case reports]. / Intoxication au méthamidophos: toxicité neurologique immédiate et retardée; à propos de deux observations.

Méthamidophos is an organophosphorus insecticide which delayed neurotoxicity is more frequent than with other organophosphates. Authors present a case report concerning a collective poisoning after cutaneous contact: two farm labourers presented moderate cholinergic signs quickly followed by proximal neurological signs (retrobulbar ocular neuritis for one patient, thight paresthesias for the second one). These signs decreased meanwhile new neurological symptoms appeared: sensory and motor peripheral neuropathy in both patients, with a clinical aspect of OrganoPhosphorus Induced Delayed Neuropathy (OPIDN). This unusual chronology and the disappearence of all signs at the 18th month, lead the authors to diagnose a collective methamidophos poisoning in three phases: first, anticholinesterasic acute syndrome; second, an intermediate syndrome and third an OPIDN.

[Cannabis-induced arteritis vs. Léo Buerger disease. Nosologic discussion apropos of two new cases]. / Artérite du cannabis versus maladie de Léo Buerger. Discussion nosologique à propos de deux nouveaux cas.

BACKGROUND: We observed two cases of juvenile endarteritis which might suggest a possible link between Winiwarter-Buerger disease and cannabis-induced endarteritis. CASE REPORTS: Our two patients were young men aged 18 and 20 years. Both developed acute distal ischemia of the lower or upper limbs with arteriographic evidence suggestive of Winiwarter-Buerger disease. Both smoked regularly but not excessively and both used cannabis regularly. In one case, the therapeutic response to withdrawal of cannabis was good. In the second, use of cannabis continued and arterial disease persisted. DISCUSSION: The cause of Winiwarter-Buerger disease remains elusive although smoking is undoubtedly involved in the pathogenic mechanism. Our two cases recall the cannabis-induced endarteritis described in the sixties in Kif smokers in North Africa. The main clinical and radiographical features in this condition are the same as in Winiwarter-Buerger disease. CONCLUSION: Winiwarter-Buerger disease and cannabis-induced endarteritis are 2 very similar conditions. The probably rare finding of juvenile endarteritis mimicking thromboangeitis obliterans should, in our opinion, be considered as a secondary and possibly toxic effect of cannabis.

[Study of narcotics and buprenorphine prescriptions in the Provence-Alps-Côte d'Azur region]. / Etude des prescriptions de stupéfiants et spécialités à base de buprénorphine en région Provence-Alpes-Côte d'Azur.

Following the setting up by the Government of their project for the management of drug addicts, and under the guidance of the CEIP (Centre d'Evaluation et d'Information sur les Pharmacodépendances [Centre for Evaluation and Information on Drug Addiction]) in Marseille, a survey of prescriptions written on controlled-drug prescription pads was performed. The aims were threefold: to study the medicines prescribed, to follow up the legislation and to inform doctors and pharmacists. Copies of the prescriptions, dated between 1 January 1996 and 30 June 1996, which were sent by 81 per cent of the 216 pharmacies contacted in 15 towns in the Provence-Alpes-Côte d'Azur (PACA) region were studied. Various criteria, relating to writing of the prescriptions and distribution of the medicines to the patients, were coded and analysed. This survey showed that of 4 prescriptions, 3 were prescribed for maintenance and one for analgesic therapy. The patients receiving maintenance therapy were male in three-quarters of the cases, and were around 30 years old. Analgesics were prescribed in equal proportions for patients of both sexes, who were around 65 years old. Since it was put on the market, Subutex has been quickly prescribed.

[Snake bite by European vipers. A multicenter study of tolerance to Viperfav, a new intravenous antivenom]. / Envenimations par vipères européennes. Etude multicentrique de tolérance du Viperfav, nouvel antivenin par voie intraveineuse.

OBJECTIVES: To evaluate the tolerance and the effectiveness of i.v. Viperfav, a new antivenom containing F(ab')2 fragments of equine antibodies, for the treatment of European viper envenomed patients. STUDY DESIGN: Open, multicentre field trial, associated with a cohort study. PATIENTS: The study included 46 patients of either gender, nine aged less then 10 years, eight between 10 and 15 years, and 28 adults, who sustained a moderate or severe viper envenomation (Grade 2 or 3). METHOD: At the inclusion, a single infusion of Viperfav was given. Depending on the clinical course, up to four additional infusions were to have been administered at 4-hour intervals. To evaluate tolerance, all symptoms were recorded. There were three effectiveness evaluation criterion (duration of hospitalisation, course of the severity grade, recovery (sequelae)) and one subjective criteria (value of the antivenom as ascertained by investigators). RESULTS: In the 46 included patients, 79 infusions were administrated. Concerning tolerance, six mild symptoms were associated to the antivenom infusions. No severe reaction occurred. The mean duration of hospitalisation was 4 days 19 hours +/- 13 hours. A severity grade decrease by at least one point was observed in 35 patients, and all were discharged without sequelae. For the investigators the antivenom was inefficient in only two patients (grade 3 with tissue lesions). CONCLUSIONS: In comparison with literature data (5 to 10% of severe reactions attributable to the antivenom), the tolerance of Viperfav can be considered as satisfactory. As all criteria were in favour of a positive benefit to risk ratio, the authors recommend the use of Viperfav i.v. for the grade 2 and 3 envenomations instead of the current less purified antivenom, which can only be administered by the intramuscular route.

[Acute renal insufficiency caused by Amanita proxima poisoning: experience of the Poison Center of Marseille]. / Insuffisance rénale aiguë lors d'intoxication par Amanita proxima: expérience du Centre anti-poisons de Marseille.

In southern France, some Amanita species are usually eaten like Amanita ovoidea (Quélet, 1872) which is a common white mushroom. In same areas, a similar and less common fungus can be encountered: Amanita proxima (Dumee, 1916). The first published cases of Amanita proxima poisonings with acute renal failure have been reported in 1994 by a medical team from Montpellier. A second article was published in 1995 by physicians from Marseille. In order to evaluate the importance of the confusion between the 2 species, we looked after these mushroom poisonings collected by the Poison Centre of Marseille. We found 31 cases concerning 53 patients. We observed the first intoxication in 1968. Poisonings took place in the south of Provence. Ingestions are in 26 cases (83% of the 31 cases) due to the confusion with Amanita ovoidea. The average delay between the meal and the first signs was 13 hours and 12 minutes. All patients had gastro-intestinal symptoms, and for 14 of them, oliguria or anuria appeared in a few days after ingestion. 11 patients needed temporary dialysis, and for 10 of them, moderate hepatic cytolysis was observed. The severity of symptoms seems to be dose-dependent: we collected cases in the same family with no signs after just tasting the meal, digestive symptoms only when patients at more, and renal failure for the hungry people.

[Severe potassium dichromate poisoning after accidental nasal introduction]. / Intoxication grave au dichromate de potassium après introduction nasale accidentelle.

BACKGROUND: Nasal foreign body (NFB) is a common situation in pediatrics. Poisoning is a rare complication of NFB insertion. We report a case of acute potassium dichromate poisoning secondary to NFB insertion. CASE REPORT: Six days after insertion of a NFB, progressive occurrence of diarrhea, vomiting, nasal obstruction, acute renal failure, pancreatitis, hepatitis and drowsiness justified hospitalization of a 3-year-old girl in the pediatric intensive care unit. Acute potassium dichromate poisoning was confirmed by high plasma chromium level and by the spectrophotometric analysis of the crystal. Recovery was satisfactory with supportive treatment. An official survey allowed to discover that the crystal was freely sold and that its toxicity was unknown by dealers, while no information was given to the customers. CONCLUSION: Transmucosal absorption of toxics is an unusual severe potential hazard that should be evoked to allow a rapid management. After the discovery and withdrawal of a NFB, occurrence of systemic symptoms, even trivial, must make one suspect a poisoning. In this circumstance, analysis of the foreign body should be done, associated with toxicologic dosages. This case report illustrates that potassium dichromate poisoning is a severe medical condition and that its clinical presentation assume a large widespread of symptoms due to multiple organ involvement.

[Occlusion of the central retinal vein after vaccination against viral hepatitis B with recombinant vaccines. 4 cases]. / Occlusion de la veine centrale de la rétine après vaccination contre l'hépatite virale B par vaccin recombinant. Quatre observations.

OBJECTIVES: Hepatitis B vaccination has been proven to be effective and well-tolerated. Certain neurological, ocular or systemic complications have, however, been reported to be induced by the vaccine. Clinicians should be aware of exceptional ocular complications. CLINICAL REPORT: Four patients under 50 years of age developed occlusion of the central vein of the retina after vaccination with recombinant hepatitis B vaccine. None of the classical causes of occlusion of the central vein of the retina could be evidenced. DISCUSSION: Several pathophysiological hypotheses have been proposed to explain these ocular manifestations after vaccination: role of immunocomplexes, antigenic cross-reactions, role of immediate hypersensitivity, simulation of a pathogenic lymphocyte repertoire. None of these hypotheses is entirely satisfactory. It is important however to emphasize the need for a complete general evaluation, including an ophthalmological examination in the presence of unexplained ocular manifestations following hepatitis B vaccination.

[Mass ciguatera poisoning after eating barracuda in Mexico: prognostic and therapeutic implications]. / Intoxication collective ciguatérique après ingestion d'un barracuda au Mexique: deductions pronostique et thérapeutique.

Thirty patients were admitted to the Anti-Poison Center of Marseille, France, on the fifth day of ciguatera fish poisoning due to ingestion of the same barracuda in Mexico. The purpose of this prospective study conducted during management of this group was to identify prognostic factors and evaluate the efficacy of treatment using mannitol. Upon admission severity was individually scored based on clinical findings. Twenty-two patients exhibiting the highest severity scores were immediately treated by infusion of 250 ml of 20% mannitol within one hour. These patients presented low plasma cholinesterase levels. Treatment led to transient improvement mainly with regard to cramping and digestive manifestations. All patients who presented high severity scores upon admission reported persistent manifestations lasting between 1 and 7 months. In 6 of these patients symptoms recurred after ingestion of seafood and/or alcohol. The fact that the extent of clinical symptoms in terms of severity and duration was correlated with the amount of fish ingested confirms that ciguatera poisoning is dose-dependent in man. However cholinesterase levels were not correlated with the severity of clinical manifestations.