[Cultural aspects in depression masked by psychotic symptoms in Maghreb countries: three case reports]. / Aspects culturels dans la dépression masquée par des symptômes psychotiques.

CASE REPORTS: In this study, we will describe three observations of depression "masked" by persecution delirium and/or hallucinations, to illustrate the role that the cultural factor could play in the expression and care of depression. In the first two observations, the persecutor was a group that was apparently difficult to circumscribe: the persecution appeared more important than the persecutor. In these two cases, persecution also had a depreciating role for the patient. In the third observation, the hallucinatory manifestations cast a slur on self-esteem and caused narcissistic injury. DISCUSSION: Analysis of the cultural context allows us to understand the depressive significance of such psychotic symptoms. In the traditional societies, depression is strongly related to the cultural context, it is often expressed by the fear of being punished or denied by the group, and a feeling of treason towards the community. The punishment can be direct or indirect, carried out by imaginary beings, "the djinn", or by any disease. According to Freud, the guilt is expressed by the fear of the vengeance of a dead man's spirit, which is then going to persecute the culprit. This persecution, which has a value of punishment, is based on the mechanism of the projection. In the same sense, Freud explained that the death, as a sequel of the disease, is the vengeance of the dead man's spirit in the living. In all religions, the impulses, the thoughts disapproved by the community, are attributed to Satan who etymologically means "the enemy" or "the opponent". This latter plays an important role in relieving fears, the sense of guilt and the disapproved thoughts. There is also involvement of the projection mechanism. So, guilt could be expressed by delirious ideas such as the conviction of being the victim of a demonic possession, to be under a spell or to be persecuted. CONCLUSION: Thus, taking the cultural context into account would allow us to fundamentally understand the depressive meaning of the delirious symptomatology of persecution, which is taken from a popular theory of misfortune shared and validated by the familial and the social circle of acquaintances. Plantine postulates that the psychotic conflict takes the subject away from the standards of his own culture. In the case of our three patients, we should try to establish a form of communication, to prevent them from falling into alienation. Thus, we must think about our attitude facing a patient who is diagnosed as depressed or even psychotic, while the patient believes he/she is possessed by a "Djinn". The therapeutic attitude should be adapted to the cultural dimension of the case. Thus, in situations similar to the studied cases, the therapy should be essentially based on the development of a psychotherapeutic relationship, rather than a pharmacotherapy, one should be careful not to compromise the cultural means of restoring psychic disorders such as the traditional therapy.

[Rethink the panic disorder]. / Repenser le trouble panique.

INTRODUCTION: We propose some reflexions on the validity of the conceptualization of panic disorder, its nosographical place, and its clinical homogeneity, through the study of the frequency of some of its psychiatric comorbidities. BACKGROUND: To define a panic attack, DSM IV requires a number of symptoms which vary from four to 13. However, some patients suffer from panic attacks with less than four symptoms (paucisymptomatic attacks) and which fill the other criteria of panic disorder. These patients would have a biological vulnerability, familial antecedents, and a treatment response which are similar to those that fill the criteria of the panic attack according to the DSM. Some authors differentiate the panic disorder in several sub-groups, such as the panic disorder with cardiorespiratory symptoms, or vestibular symptoms, or cognitive symptoms. This division of the panic disorder in several sub-groups would have an interest in the knowledge of the etiopathogeny, the attacks' frequency, the disorder severity and the treatment response. Panic disorder with prevalent somatic expression includes crises without cognitive symptoms. This sub-type can be common in the medical context, especially in cardiology, but it is often ignored, at the price of loss of socio-professional adaptability, and a medical overconsumption. DISCUSSION AND ARGUMENTS: The relationship between panic disorder and agoraphobia appears to be the subject of controversies. According to the behavioral theory, phobic disorder is the primum movens of the sequence of appearance of the disorders. American psychiatry considers agoraphobia as a secondary response to the panic disorder, and pleads for a central role of panic attacks as an etiopathogenic factor in the development of agoraphobia. The distinction between panic disorder and generalized anxiety disorder can be difficult. This is due to the existence of paucisymptomatic panic attacks. Their paroxystic nature is difficult to distinguish from the fluctuations of the generalized anxiety disorder. This frequent comorbidity could be also due to the community of certain symptoms of each disorder. These observations increase the validity of the anxiety generalized disorder as an autonomous morbid entity, rather than corresponding to a residual syndrome of the panic disorder, and could be an argument of an implicit return to the Freudian concept of the anxiety neurosis. The frequent comorbidity of panic disorder and personality disorders suggests the existence of a link. The pathological personality can be a factor of vulnerability in the panic disorder, as it can be a consequence of the panic disorder through the personality changing related on the evolution of the disorder and its complications. The relationship between panic disorder and depression has been interpreted in various ways, with mainly three assumptions: the unit position, which considers anxiety and depression as concerning a common diathesis; the dualistic position, which suggests that anxiety and depression are heterogeneous diagnostic categories and the anxio-depressive position that considers anxiety and depression combined as a syndrome differing from the pure anxiety and pure depression. The genetic studies, as well as the family studies, clearly show that the two entities are undissociated. Likewise, the therapeutic action of serotoninergic antidepressants in the two types of disorders reinforces the idea of a common biological vulnerability between anxiety and depression. Several studies have shown a significant association between panic disorder and suicide. However, the suicidal conducts are multiple and proceed by complex interactions between factors of features and states. Accordingly, panic disorder can be considered as a factor of state associated with the suicidal risk.

MHC class I and class II genes in Tunisian patients with reactive and undifferentiated arthritis.

OBJECTIVE: To study HLA class I and class II association in Tunisian patients with reactive (ReA) and undifferentiated arthritis (UA). METHODS: The study included 17 patients with ReA defined according to the European Spondylarthropathy Study Group criteria for spondylarthropathy (SpA), 11 patients classified as having undifferentiated arthritis and 100 unrelated healthy controls. HLA class I antigens were typed serologically and HLA class II alleles were genotyped molecularly by the polymerase chain reaction with sequence-specific primers technique. RESULTS: There was a major difference between HLA alleles in ReA and UA patients when compared separately with controls. Increased frequencies of HLA-B27 (p=7.76 10-12, OR=59.30), HLA-B51 (p=0.015, OR=4.91) and HLA-DRB1*04 (p=0.033, OR=2.90) alleles were found in patients with ReA but not in patients with UA. HLA-B27 was not expressed totally in our cohort of UA patients. A significant increase of HLA-B15 (p=0.002, OR=18.40) and a moderate increase of HLA-B7 (p=0.043, OR=5.15) was found in patients with UA, but not in patients with ReA. In the B27 negative patients, HLA-DRB1*04 association with ReA was found independently of B27. CONCLUSION: Our data confirmed a significant association of HLA-B27 with ReA in the Tunisian population. Our results also suggested that some of the additional HLA antigens were associated with ReA including HLA-B51 and HLA-DRB1*04 alleles. UA seemed to have a genetic background different from ReA in Tunisian patients.

[Patelar metastasis of primary lung cancer]. / Métastase rotulienne d'un cancer broncho-pulmonaire primitif.

Patellar metastasis is uncommon. The clinical presentation is often misleading, suggestive of septic arthritis or meniscal disorder after knee trauma. We report the case of a 71-year-old patient who developed knee pain aggravated by movement with pseudo-blockage which was found to be related to a secondary localization of a primary lung cancer. Low blood flow in the patella probably explains why patellar metastasis is so rare.

[Intramuscular myxoma. Apropos of two cases]. / Myxome intra-musculaire. Apropos de deux localisations.

The authors report two cases of rare localization of intra muscular myxoma: one in the buttock, and the other in the lumbar area. The first case, a 58 years old woman had a four month history of a mass in the buttock. Computed tomography revealed the presence of a solid tumor. Diagnosis was based on histological examination. After surgical treatment no recurrence was observed after fourteen months. The second case was a 54 years old woman who presented a sciatica with back pain and neurological signs. The symptoms didn't response to medical treatment. Computed tomography showed an enlarged and-cystic lumbar lesion extending to the first sacral hole, with bone erosion of L3 and L4 articular apophysis and spinous process. Needle biopsy and surgical excision of the tumor were performed. Total neurological recovery was observed and no recurrence was observed after three years. The authors reminded the characteristics of this rare and benign soft tissue tumor and specified the place of magnetic resonance imaging (MRI) to establish the diagnosis which was still confirmed by histological examination of an open biopsy. Clinical follow-up revealed exceptional recurrence and no metastasis.

[Osteoid osteoma of the spine. Radiological study of 21 cases]. / Ostéomes ostéoïdes du rachis. Etude radiologique de 21 cas.

Spinal osteoid osteomas are rare. We report 21 cases, that have been studied and treated since 1985. The tumor affects young people, who are less than 25 years old. The pain is the most common sign. Diagnosis is difficult, but can be made by radiology. X ray sometimes enables to suspect the diagnosis. Scintigraphy shows a focus hyperfixation more suggestive. Computed tomography enables the diagnosis by showing a bony lacuna surrounded by osteosclerosis. Moreover, computed tomography localizes very well the nidus of the osteoid osteoma, and guides the surgical treatment. Since computed tomography, other techniques like angiography and tomography are less used for diagnosis.

Case report: hydatid cyst of the aorta.

We report a rare case of hydatid cyst presenting as a 13 cm cyst in the wall of the lower mediastinal portion of the thoracic aorta associated with splenic and peritoneal cysts. The diagnostic problems are discussed.

[Isolated posterior pre-marginal hernia. Apropos of 6 cases]. / La hernie pré-marginale postérieure isolée. A propos de 6 cas.

Posterior pre-marginal disk hernia, a rare lesion, was diagnosed in six young adults with lumbago. Lateral lumbar spine radiographic images showed an unusual appearance, combining a posterior marginal defect of a vertebral corner and a small bony spicule projecting into lumbar canal. A literature review revealed 27 similar cases, mostly in adolescents. These vertebral disk anomalies are considered by some authors to be fractures of the posterior margin border. A more plausible hypothesis is a pre-marginal hernia, because of lack of a history of injury, the radiologic appearance comparable with that of sequelae of Scheuermann's disease, and the frequent association of these lesions with a spinal growth dystrophy.

Primary osteosarcoma of the cervical spine: one case.

The authors report the case of a 31-year old woman who was operated upon for cervical bone tumour. The pathological study showed that it was a primary, highly differentiated osteosarcoma. The clinical picture was limited to a spinal cord compression syndrome without signs of inflammation. Radiological findings were non-specific. Treatment consisted of laminectomy, radiotherapy and chemotherapy. The course of the disease was marked by stabilization, then rapid aggravation 2 years after the operation. A review of the literature highlighted the rarity and relatively slow progression of primary osteosarcomas of the spine.

[A misleading manifestation of urogenital schistosomiasis in man]. / Une manifestation trompeuse de la bilharziose uro-génitale chez l'homme.

Lesions of seminal vesicles during urogenital schistosomiasis are a frequent finding but their manifestation as a palpable mass is a rare feature. An exceptional case of a large schistosomial spermatocyst is reported in which diagnosis was by histopathology.