[Persistent aphthous mouth ulcers associated with tocilizumab: two cases]. / Ulcérations buccales aphtoïdes persistantes associées au tocilizumab: deux cas.

BACKGROUND: Tocilizumab, a humanized monoclonal antibody that blocks interleukin-6 receptor, is approved for use in rheumatological diseases. The most frequent adverse events reported are infections. We describe for the first time the occurrence of recurrent aphthous mouth ulcers in two patients on TCZ. PATIENTS AND METHODS: Two patients were treated with TCZ for rheumatological disease. A few weeks after administration of TCZ, they presented with multiple painful mouth ulcers that would not heal until TCZ had been withdrawn. In both cases, the oral ulcers resolved 6 to 7weeks after withdrawal of TCZ and readministration of the drug led to recurrence of oral ulcers within 10days in both patients. DISCUSSION: We describe for the first time the occurrence of aphthous mouth ulcers induced by TCZ. The causative role of TCZ was established by positive rechallenge. These cases were similar to a recently reported case of multiple intestinal aphthous ulcers occurring during TCZ treatment. Such mucosal side effects may be explained by similar inflammatory mechanisms but appear paradoxical because TCZ inhibits a pro-inflammatory cytokine, interleukin 6. TCZ treatment can be maintained if necessary, in combination with colchicine, as reported for one of our patients.

[The value of allergy survey in a retrospective series of 40 patients with burning-mouth syndrome (stomatodynia)]. / Stomatodynies: intérêt de l'enquête allergologique dans une série rétrospective de 40 malades.

BACKGROUND: By definition, stomatodynia or burning-mouth syndrome involves oral pain with no causes being found on history taking or examination. An allergic origin is often suspected by doctors and patients alike. In this study, we attempted to assess the value of epicutaneous tests in demonstrating allergic causes for patients presenting stomatodynia. PATIENTS AND METHODS: This was a single-centre retrospective study of patients undergoing epicutaneous tests between 1996 and 2003 to screen for allergic causes of mouth pain not accounted for by any abnormalities seen during examination performed at consultations for mouth disease. RESULTS: Forty patients were included (11 male, 29 female; mean age: 58 years), and 39 were excluded. Sixteen patients presented at least one positive test, with a total of 35 positive tests in all. In decreasing order of frequency, the causes were metals, mercury derivatives (nickel salts: n=5; chrome salts: n=3; palladium salts: n=2; phenylmercuric acetate: n=2; thiomersal: n=2; cobalt salts: n=1; gold salts: n=1; mercury: n=1) and resins (acrylates: n=4). The relevance of these test results was considered probable in three cases and possible in five cases, associated with the existence of metals or resins in patients' mouths. The Peru balm test was positive in four cases but was not relevant. Tests for personal products were negative in all cases, with the exception of one case of resin from a prosthesis and one case of tixocortol pivalate. COMMENTS: Type I stomatodynia (daily occurrence with gradually increase in discomfort throughout the day) and type II stomatodynia (permanent) are not normally attributable to allergies. However, for type III stomatodynia (non-permanent, with acute episodes followed by remission), an allergy survey guided by questioning may be undertaken to determine the cause, primarily prostheses or diet. The relevance of positive test results must be interpreted with caution in view of the incidence of positive epicutaneous tests for metals and Peru balm among the general population studied.

[Acquired bullous diseases of the oral mucosa]. / Maladies bulleuses acquises de la muqueuse buccale.

Bullous diseases of the oral cavity cause painful erosion. They must be distinguished from aphthae and vesicles which may have a similar presentation. Acute, chronic and congenital conditions are recognized. Acute lesions may involve a polymorphous oral erhythema which has an polymorphous erythematous presentation or toxidermia (Stevens-Johnson syndrome, Lyell syndrome, fixed pigmented erythema). Examination of the skin and history taking are the keys to diagnosis. Patients with chronic bullous diseases may have a congenital condition (bullous epidermolysis or lymphangioma) suggested by the age at onset and the clinical presentation. Acquired chronic bullous diseases include lichen planus and autoimmune bullous diseases. Careful examination is essential to identify mucosal or cutaneous involvement and to obtain a biopsy for histological examination. Search for antibodies deposited in the perilesional mucosa is necessary. Chronic erosive gingivitis is a frequent presentation. Most of the patients have cicatricial pemphigoid, lichen planus, and more rarely pemphigus. The pinch sign is highly discriminative to differentiate the cause of this syndrome. Symptomatic treatment of bullous lesions of the oral cavity include adapted diet and correct and early use of antalgesics.

[Clinical manifestations of the mouth revealing Vitamin B12 deficiency before the onset of anemia]. / Signes buccaux révélateurs d'une carence en vitamine B12 avant l'apparition d'une anémie.

INTRODUCTION: The association of manifestations in the mouth and Vitamin B12 deficiency is already known. The signs are not specific to Vitamin B12 deficiency, however they may reveal the deficiency and this is often ignored and leads to delays in diagnosis. We report two cases of Vitamin B12 deficiency revealed by stomatodynia, glossitis and erosions in the mouth. OBSERVATIONS: Two women aged 51 and 76 years consulted, one for atrophic glossitis and the other for stomatodynia that had progressed over the past few months. No other symptoms were present. The biological examinations revealed isolated macrocytosis without anemia. Vitamin B12 could not be measured in the serum. The symptoms regressed in less than one month following replacement therapy. DISCUSSION: As with our two patients, the majority of cases of Vitamin B12 deficiency reported in the literature were only discovered several months or years after their onset, or were treated for other causes. Vitamin B12 deficiency leads to severe neuropathies. The neurological damage is reversible when replacement therapy is initiated early. Since the oral signs appear before the modification in the systemic markers of deficiency, it is crucial that these signs be recognized and diagnosed before the occurrence of severe after effects.

[Recurrent aphthous stomatitis: treatment with colchicine. An open trial of 54 cases]. / Aphtose buccale récidivante: traitement par colchicine. Etude ouverte de 54 cas.

INTRODUCTION: Colchicine is a treatment used for aphthous stomatitis but its efficacy has never been proved. We report the results of an open trial of 54 patients treated with colchicine for aphthous stomatitis. The aim of our study was to assess the long and short term efficacy and tolerance of this molecule in this disease. PATIENTS AND METHODS: The case reports of 64 patients presenting with severe, recurrent aphthous stomatitis treated with colchicine between 1986 and 2000 were analyzed retrospectively. Only immunocompetent patients exhibiting idiopathic aphthous stomatitis or Behçet's disease were included. Ten patients were excluded: 4 cases of Behçet's disease treated with colchicine and systemic corticosteroids, 4 cases of aphthous stomatitis secondary to a hematological cause and 2 patients who were lost to follow-up after 3 month's treatment. Colchicine was prescribed at a dose of 1 to 1.5 mg/d for at least 3 months. All the patients were assessed after 3 month's treatment and all were contacted by phone in May 2000. Our end-point criteria were: the frequency and duration of the episodes, intensity of pain and impact on the quality of life of the patients. RESULTS: Fifty-four patients were included: 39 women (mean age=44 +/- 16.8) and 15 men (mean age=49 +/- 13.5). The disease had progressed for a mean of 11.6 +/- 13.5 years. After 3 month's treatment, 12 patients (22 p. 100) no longer had aphta and were in complete remission, 22 patients (41 p. 100) were significantly improved, since the frequency and duration of the lesions had decreased by at least 50 p. 100 and the latter were no longer painful. Treatment failed or tolerance was poor in 20 patients (37 p. 100). Patients were monitored and assessed for a mean of 4.7 years (range: 6 months to 13 years). Six patients were lost to follow-up. Three patients (6 p. 100) were considered as cured, since they were still in complete remission after suspension of colchicine respectively 6, 24 and 72 months later. Fifteen patients (31 p. 100) had still improved. Among the latter, 10 continued colchicine for a mean of 27 months, and 5 patients stopped treatment, which they considered tedious, after a mean of 16 months. These 15 patients noted a significant reduction in the frequency and duration of the lesions. Moreover, the subjective end-point criteria had improved significantly for them not to wish to change treatment. Thirty patients (63 p. 100) were not improved by the treatment. Some benign adverse events were noted in 10 patients (18.5 p. 100) and led to suspension of treatment in 4 cases. DISCUSSION: This study, which is the first in size (n=54) and duration of follow-up (4.7 years), showed that colchicine is an efficient preventive treatment of severe aphthous stomatitis for 63 p. 100 of patients after 3 month's treatment and that this improvement was lasting in 37 p. 100 of them. Colchicine should therefore be proposed in first intention in severe recurrent aphthous stomatitis, since it is effective, well tolerated and easy to use.

[Paraneoplastic pemphigus: a pustular form during chronic lymphoid leukemia]. / Pemphigus paranéoplasique. Une forme pustuleuse au cours d'une leucémie lymphoïde chronique.

BACKGROUND: Paraneoplastic pemphigus is an autoimmune disease of the skin and mucosa described in 1990. The condition is generally associated with lymphoma or chronic lymphoid leukemia. Lesions are often misleading, masquerading as polymorphous erythema or lichen. We report a case of paraneoplastic pemphigus with pustulous skin lesions. CASE REPORT: A 52-year-old man developed over a few weeks time erosive lesions of the oral cavity and lips associated with papulous skin lesions. Secondarily, large-sized pustules, sometimes a hypopion, were observed associated with bullae. The diagnosis of paraneoplastic pemphigus was confirmed by direct immunofluorescence that evidenced IgG deposits within the keratinocytes and along the basal membrane and by indirect immunofluorescence on rat bladder that evidenced circulating antibodies. This paraneoplastic pemphigus was the inaugural sign of chronic lymphoid leukemia. DISCUSSION: Skin lesions described in paraneoplastic pemphigus include: erosion, vesicles, bullae, and psoriasiform, lichen-like, plate-like or vegetative formations. To our knowledge, this is the first report of a pustulous form; clinically similar to Hallopeau pustulous pemphigus.

[Chronic desquamative gingivitis syndrome: retrospective analysis of 33 cases]. / Le syndrome "gingivite érosive chronique": étude rétrospective de 33 cas.

OBJECTIVE: Desquamative gingivitis is a chronic diffuse inflammation of the gingiva. The aim of this study was to determine the causes and the clinical characteristics of desquamative gingivitis. PATIENTS AND METHODS: This was a retrospective descriptive study including 33 consecutive patients (25 women and 8 men) seen at a dermatology clinic for erosive gingivitis. RESULTS: Thirteen patients (39 p. 100) had cicatricial pemphigoid, 12 (36 p. 100) had lichen planus, and 5 (15 p. 100) had pemphigus. Delay to diagnosis was a mean 19 months. The pinch sign was positive in 12 of the 13 cases of cicatricial pemphigoid. Dapsone improved the buccal lesions of cicatricial pemphigoid in all cases. Systemic corticosteroid therapy and acitretine were the most effective treatments for lichen planus and corticosteroid therapy improved pemphigus in all cases. At the time of assessment, only 3 cases of cicatricial pemphigoid, 2 cases of lichen planus and 1 case of pemphigus had reached complete remission without treatment. DISCUSSION: Cicatricial pemphigoid and lichen planus are the most frequent causes of desquamative gingivitis, accounting for three-quarters of the cases. Positive diagnosis may be difficult and may require sophisticated techniques to avoid delay. Despite the effectiveness of symptomatic treatment, desquamative gingivitis may have a long course.

[MALT lymphoma with parotid and gastric involvement during Gougerot-Sjögren syndrome]. / Lymphome du MALT à localisation parotidienne et gastrique au cours du syndrome de Gougerot-Sjögren.

Sjören syndrome favors the development of lymphoma, particularly in the salivary glands with MALT lymphomas. The differential diagnosis with benign lymphoepithelial sialadenitis can be difficult. A 78-year-old woman had an oculo-buccal sicca syndrome for 10 years and developed parotid hypertrophy. The first biopsy, performed 7 years before the present investigation had showed chronic lymphoepithelial sialadenitis. A second biopsy showed MALT lymphoma. Search for extension revealed a second gastric localization of the lymphoma. This patient had a particular immunophenotype, showing a CD5+ tumoral population frequently observed in mantel lymphomas and usually lacking in MALT lymphomas. Recently, however, another case similar to our own, has been reported in the literature. The observations raise the problem of distinguishing between mantel lymphoma and MALT lymphoma.

[Benign symmetrical lipomatosis of the tongue]. / Lipomatose bénigne symétrique de la langue.

INTRODUCTION: Lipomatosis of the tongue is rarely observed. CASE REPORT: An 85-year-old man with chronic alcoholism presented several symmetrical lipomas of the tongue with no other clinical manifestations. There was no capsule at the histology examination. DISCUSSION: The multiple and symmetrical nature of the lesion without a capsule led to the diagnosis of benign symmetrical lipomatosis of the tongue, the fourth case reported in the literature.

[Skin carcinoma of the face: surgery or radiotherapy?]. / Carcinomes cutanés de la face: chirurgie ou radiothérapie?

Surgical exeresis and radiation therapy are effective means of treatment for facial carcinomas. In some areas that are difficult to manage (nose, ears, periorbital region), the respective importance of both approaches is discussed. We report on the retrospective study of 309 patients seen after a skin carcinology consultation in which a dermatologist, a surgeon and a radiotherapist were associated. These 309 patients, with a mean age of 73 years, presented with 375 carcinomas, i.e. 246 basal-cell (BC) and 119 epidermoid (EC) carcinomas. The most frequent sites were the nose (33.8% of BC), the inner canthus (12.7% of BC), the lower lip (23.8% of EC) and the ear (15.6% of EC). Management mainly consisted of surgery (50.8%) then Curie therapy (37%). The rate of recurrence was the same (10.5%) after surgery and radiation therapy. The study of the results leads us to advocating surgery for carcinomas of the ear (due to the occurrence of radiation necrosis in every third case after radiation therapy) and Curie therapy for carcinomas of the lower lid (except the inner canthus) because of recurrence in every second case treated with surgery. We currently prefer surgery for carcinomas of the lower lip (radiodermatitis in 11.8% of cases) and Curie therapy for the nose (lower rate of recurrence than with surgery). However, in the last two cases, the proposals for treatment should be confirmed by randomized studies. Thus facial carcinomas of the skin surrounding the orifices of the face and/or those that affect patients who are difficult to treat must be seen during a skin carcinology consultation by a dermatologist, a surgeon and a radiotherapist working together.(ABSTRACT TRUNCATED AT 250 WORDS)