[Antibiomania: Think of the manic syndrome secondary to antibiotic therapy]. / Antibiomania : penser au syndrome maniaque secondaire à une antibiothérapie.

INTRODUCTION: Antibiomania is characterized by the emergence of a manic episode in reaction to antibiotics. Although relatively uncommon, this kind of side effect is observed in a growing number of cases and mostly occurs in patients who do not have a history of bipolar disorder. Several dozen cases have been reported showing the onset of manic symptoms after taking antibiotics. The antibiotic most frequently involved is clarithromycin. CLINICAL CASE: We report the case of a 61-year-old patient who presented a manic episode after taking an antibiotic combination to treat Helicobacter pylori. Five days after the start of highly active antiretroviral therapy (HAART), behavioral problems appeared (aggressiveness, irritability, talkativeness, insomnia). At the time of hospitalization, she had an acute delusional symptomatology, with a theme of persecution, associated with intuitive, interpretive and imaginative mechanisms. Manic symptoms were obvious: psychomotor excitement, aggressiveness and irritability, flight of ideas, verbal disinhibition and a denial of problems. There was no toxic cause. Brain magnetic resonance imaging (MRI) was normal. Her condition improved very quickly and delusions disappeared in four days. Mrs. H. could critic her delirium and recovered a euthymic state. During hospitalization, treatment divalproate sodium was introduced (250mg, 3 times a day), was maintained following hospital discharge for 2 years for prevention, and then decreased to the stop. There are currently no further behavioral problems or sleep disorders two years after this episode. DISCUSSION: Facing this clinical case, several questions arise: Which drug therapy is the most suitable for this type of mental disorder? Are there predictors of antibiomania? Is there a risk of recurrence of mood episodes following an antibiomania that occurs spontaneously? What are the pathophysiological mechanisms that could explain this reaction? In all cases identified, stopping the antibiotics was decisive. However, the introduction of a psychotropic and the duration of this treatment remain unclear. First, longitudinal follow-up would assess this variable. Second, it is unclear whether the presence of personal psychiatric history is a predictor of antibiomania. Finally, there are several hypotheses to explain antibiomania: the competitive effect of GABAergic inhibitory receptors, seizure-like phenomena that mimic psychiatric symptoms, and disruption of the intestinal microbiota by antibiotics leading to a modification of the functioning of the central nervous system. The explanatory model of antibiomania is not yet known and requires further research.

[Tetralogy of Fallot in adults. Apropos of 43 cases with 38 total corrections]. / La tétralogie de Fallot chez l'adulte. A propos de 43 observations avec 38 corrections complètes.

The records of 43 patients older than 18 years presenting with tetralogy of Fallot were retrospectively examined to determine the semiological characteristics of the disease in adults. One or more palliative operations had previously been performed in 27 patients. Full correction was carried out in 38 patients with results described below. Tetralogy of Fallot has the following characteristics in adults as compared with children: clinically, heart failure, attacks of angina, haemoptysis and sequelae of previous complications are more frequent; at electrocardiography, right atrial hypertrophy, right bundle disorders of conduction and ventricular extrasystoles are also more frequent; radiology shows that cardiomegaly is no longer exceptional; haemodynamic studies demonstrate an increase in right atrial and right ventricular end-diastolic pressures. These characteristics indicate a deterioration of haemodynamic adjustment to the disease with age. The operative morbidity mostly consisted of haemorrhages (55% of the patients), more frequent in subjects with permeable anastomoses (p less than 0.01), and heart failure (50% of the patients) the frequency of which increased with the subject's age, the duration of the operation and the use of an infundibulo-pulmonary prosthesis (p less than 0.05). The operative mortality (18%) depended on the extent of the pulmonary stenosis and on the presence of a previous anastomosis (p = 0.04). An analysis of the causes of death reported in the literature showed that in adults the presence of an anastomosis constitutes a separate risk factor in complete repair. The excellent long-term results of corrective surgery concerning cardiac function and survival suggest that except for those rare cases where the operative risk is very high all adults with tetralogy of Fallot should undergo complete repair.

[Collateral pulmonary circulation in Fallot's tetralogy]. / La circulation pulmonaire de suppléance dans la tétralogie de Fallot.

An angiographic study of 231 patients with tetralogy of Fallot (TOF) in both neonatal and adult age groups (0 to 49 years) was in this condition. Cases of pulmonary atresia with ventricular septal defect were excluded. Two types of collateral pulmonary circulation were observed: the most common form is the result of distal intrapulmonary anastomosis between systemic parietal, mammary and bronchial vessels with the pulmonary arteries. This type of collateral circulation represents an evolutive stage of TOF and is directly related to age and to the degree of hypoxia; the other, oa rare and probably congenital form (1.7 p. 100 of cases) observed even in young children, consisting of proximal anastomoses between systemic vessels arising from the aorta (1 to 3 vessels) and the pulmonary arterial tree. The rare forms of TOF with single pulmonary arteries acquired after palliative or congenital anastomoses (1.4 p. 100) have both types of collateral circulation. Preoperative diagnosis of the collateral pulmonary circulation requires opacification of the aorta especially of the descending thoracic segment and its branches, completed in cases of an absent pulmonary artery by wedged pulmonary venous opacification. The haemodynamic effects of this collateral circulation on the pulmonary bed to a variable degree of histological change. This may partially explain some of the poor surgical results of repair of TOF and, in view of recent progress in cardiopulmonary bypass techniques in children, incite to earlier surgical correction of this condition.

[Large aneurysm of the left heart, an unusual cause of cardiomegaly in children]. / Le volumineux anévrysme du coeur gauche, une cause exceptionnelle de cardiomégalie chez l'enfant.

Idiopathic left ventricular aneurysms are rare in childhood as are the congenital epigastric muscular diverticula which form part of a complex congenital malformation. The aneurysms are usually symptomatic and present either with cardiac failure or another complication. The authors report a very rare case in which the aneurysm effectively realised a double chamber left ventricle. The aneurysm was larger than the true ventricle, muscular, lined by normal endocardium and covered by coronary vessels. Surgical ablation was indicated for cardiac failure. Two similar cases have been previously reported.

[Idiopathic dilatation of the right atrium in 2 infants disclosed by arrhythmia]. / Dilatation idiopathique de l'oreillette droite révélée chez deux nourrissons par des troubles du rythme.

Idiopathic right atrial dilatation is a rare and probably congenital malformation. Two new cases are reported, in an 18 months old infant and a six week old baby, both presenting with supraventricular tachyarrhythmias. Clinical examination was normal. Chest X-ray showed bulging of the right heart border and electrocardiography revealed partial right bundle branch block. The diagnosis was made by echocardiography which showed aneurysmal dilatation of the right atrium. There were no signs of valvular heart disease or of an intracardiac shunt; the septal tricuspid leaflet was in its normal position. M-mode recordings showed no signs of Ebstein's anomaly. The diagnosis was confirmed by cardiac catheterisation in the first case; this investigation seemed to be pointless in the second case. Both children experienced many episodes of supraventricular tachyarrhythmias. The first developed tricuspid regurgitation but the second remains asymptomatic.

[Noninvasive evaluation of aortocoronary bypass graft patency with tomodensitometry and exercise myocardial scintigraphy]. / Evaluation atraumatique de la perméabilité des pontages aorto-coronariens par la tomodensitométrie et la scintigraphie myocardique à l'effort.

The control of the patency of aortocoronary bypass grafts necessitates further coronary angiography, an invasive investigation which is difficult to perform routinely because over 60 p. cent of operated patients are asymptomatic. Non-invasive methods have been proposed for this task, including computerised axial tomography (CAT) and exercise Thallium 201 myocardial scintigraphy (EMS). The aim of this study was to assess the relative value of CAT and EMS, alone and in association, in comparison with coronary angiography. Thirty six patients (35 men, 1 woman) with a mean age of 54 years were studied. These patients had a total of 59 bypass grafts inserted an average of 23 months before investigation (20 single, 10 double, 5 triple and 1 quadruple bypass grafts). CAT scanning was performed the day before coronary angiography. Sections of the thorax 7 mm thick were recorded after intravenous injection of contrast medium. A patent graft was identified as an opacity increasing after the injection of contrast on one of the aortic walls. During coronary angiography a graft was declared to be patent when it was opacified selectively or during aortography, and when the grafted coronary artery was seen to be revascularised. The quality of the distal coronary bed was also evaluated (implantation of the graft, distal and collateral vessels). Twenty three patients (with a total of 36 grafts) also underwent EMS on the same day as CAT scanning. Normal fixation in the revascularised territory was taken as evidence of a patent graft. --Coronary angiography showed that 44/59 grafts were patent at 24 months. --CAT scanning was unable to evaluate 12/59 grafts. Thoracic metallic clips created stratified artifacts and analysis of the section was impossible (20 p. cent of CAT investigations were non-contributive); of the interpretable investigations, 40/47 grafts were correctly assessed (85 p. cent): 30/32 patent grafts and 10/15 occluded grafts. --The results of EMS were less reliable; 23/36 grafts correctly assessed (64 p. cent), 18/27 patent grafts and 5/9 occluded grafts. However, EMS provides complementary information to that provided by CAT scanning, especially with respect to the distal coronary bed. When the two methods were used together, 15/15 good surgical results (patent grafts with good distal vascularisation) and 6/8 poor results (patent grafts but poor distal vascularisation), were identified. We conclude that these two atraumatic methods, CAT scanning and EMS, which may be performed on out-patients, are valuable for the routine assessment of the patency of coronary bypass grafts. Coronary angiography could therefore be reserved for those patients in whom further surgery is being considered.

Myocardial macroaggregate uptake on successive lung perfusion scans.

In a patient with an Eisenmenger syndrome and multiple intraventricular communications, myocardial uptake of macroaggregated albumin appeared during a perfusion lung scan. This pattern can be explained by an increase of arterial pulmonary hypertension heightening the proportion of the right-to-left shunt.

[Bacterial endocarditis in congenital heart diseases]. / Endocardites bactériennes sur cardiopathies congénitales.

The following observations were made on a series of 15 cases of bacterial endocarditis on congenital cardiac lesions admitted between 1971 and 1980, in 13 patients aged 6 to 48 years old (average 21 yrs old): --The low but constant incidence of endocarditis--The majority of causal lesions were ventricular septal defects of Fallot's tetralogy--The portal of entry diagnosed in 2/3 of cases was usually dental--The causal organism was a streptococcus in 80% of cases--The long period of pyrexia before, the diagnosis of endocarditis was made--M mode, and above all, 2D echo detected vegetations in half the cases where it was performed--The gravity of the immediate prognosis due to a 25% mortality and a high incidence of complications--Early complications present in 2/3 of cases were dominated by true "oslerian" lesions, cardiac failure, cerebral complications, pulmonary embolism and early relapse. --The relatively good secondary prognosis.

[Infectious endocarditis of a healthy heart in an infant]. / Endocardite infectieuse sur coeur sain chez un nourrisson.

The case of a 22 months old child with no previous medical history hospitalised for an acute infection with pyrexia, arthritis, meningitis and leukocytosis with polynucleosis is reported. All bacteriological investigations were sterile; the search for soluble antigen and serological tests were negative. Antibiotic therapy (Ampicillin and Thiamphenicol) cured the meningitis and arthritis. On the 10th day of treatment the temperature rose, a systolic murmur was detected and echocardiography showed the presence of a large vegetation on the anterior mitral leaflet. Three weeks later (on Ampicillin and Amikacine), asymptomatic abolition of the femoral pulses and disappearance of the vegetation on echocardiography were observed. Angiography confirmed obstruction at the bifurcation of the aorta. Surgical removal of the embolism resulted in revascularisation of the femoral artery and was followed by apyrexia. This infant probably developed endocarditis on a healthy heart. It was complicated by systemic embolism and mitral regurgitation which at present is well tolerated.

[Left coronary artery arising from the pulmonary artery : a report on two cases of this anomaly in adults (author's transl)]. / Naissance anormale de l'artère coronaire gauche (CG) dans l'artère pulmonaire (AP) chez l'adulte. A propos de deux cas.

The presence of an abnormal origin of the left coronary artery from the pulmonary artery was observed in two adults. The clinical, radiological, and hemodynamic characteristics of this disorder are described. The author emphasizes the value of exploring these malformations by means of a strict technique, including the injection of a large quantity of contrast medium.