[Fatal acute encephalopathy due to 5-fluorouracil treatment]. / Encéphalopathie aiguë fatale secondaire à un traitement par 5-fluoro-uracile.

INTRODUCTION: Encephalopathies from 5 fluorouracil (5FU) are rare and generally resolve favorably. CASE: Six days after her first course of chemotherapy combining 5FU and cisplatin, a 45-year-old woman developed acute encephalopathy with altered consciousness and convulsions. MRI showed hyperintense signals of the white matter, mainly ventricular. Despite symptomatic treatment and thiamine perfusion in intensive care, the patient deteriorated and resuscitation failed. Blood tests confirmed 5FU toxicity. DISCUSSION: 5FU encephalopathies are rare and most often resolve favorably after treatment is stopped. Two pathophysiologic mechanisms may explain these encephalopathies: a deficit of dihydropyridine dehydrogenase, leading to an increased level of serum uracil with digestive and mucosal toxicity, or interaction of 5FU catabolites with various intracerebral metabolic pathways.

Outcome after combined reperfusion therapy for acute myocardial infarction, combining pre-hospital thrombolysis with immediate percutaneous coronary intervention and stent.

BACKGROUND: Primary therapies in acute myocardial infarction (thrombolysis and angioplasty) have inherent limitations which may be overcome by combining them. So far, no trial has demonstrated a clinical benefit in combining mechanical and pharmacological treatment strategies. METHODS: From January 1995 to December 1999, out of 1010 patients admitted to our institution for acute myocardial infarction, 148 had received pre-hospital full dose thrombolysis within 12 h of onset. One hundred and thirty-one patients were included and underwent immediate angioplasty and stenting when suitable, independent of the infarct-artery patency (TIMI grade flow 0-3). In-hospital outcome was assessed and clinical information was collected for a mean (+/-SD) of 2+/-1 years. RESULTS: Ninety-minute angiography revealed a patent (TIMI grade 3) infarct artery in 65 patients (49%). Immediate angioplasty was performed in 119 patients (91%) with stent implantation in 114 (96%). Angioplasty achieved TIMI 2, 3 flow in 98%, and complete patency (TIMI 3 flow) in 92%. Six other patients underwent deferred revascularization (surgery in one patient, angioplasty in five) and six received medical treatment. Stent thrombosis and reinfarction occurred in three patients (2.3%). In-hospital death occurred in six patients (4.6%), including four patients presenting with cardiogenic shock. Major bleeding was observed in 2.3% of cases. No patient had emergency surgery. Freedom from death and reinfarction at 2 years was 90% and freedom from death, reinfarction and target vessel revascularization was 83%. CONCLUSION: A strategy of combined reperfusion using full dose pre-hospital thrombolysis and immediate angioplasty with stent implantation in a non-selected acute myocardial infarction population is safe and achieves high and early patency rates. This preliminary experience suggests that a combined strategy in acute myocardial infarction may have a significant impact on both early and long-term outcomes.