A brain mass in a patient with Behcet's disease: a case report.

INTRODUCTION: This case report describes an uncommon presentation of Behcet's disease which manifested as neuro-Behcet's disease. Although it is not the first reported case in the medical literature, it is a possible differential in a patient presenting with a brain tumor. Since the diagnosis of neuro-Behcet's disease depends largely on the clinical picture and medical history, it should be considered prior to opting for invasive diagnostic methods. CASE PRESENTATION: Our patient is a 36-year-old white man from Kuwait. He presented with acute onset of headache, vomiting, and right-sided weakness. Magnetic resonance imaging of his brain showed a mass in the brain stem. He then revealed that he had a history of recurrent painful oral and genital ulcers for the past 10 years, which suggested a diagnosis of Behcet's disease. A brain biopsy was recommended by a neurosurgeon at the time, but the patient refused the procedure. After initiating steroid therapy, the mass began to regress and, eventually, was undetectable on subsequent imaging of his brain. CONCLUSIONS: This case of neuro-Behcet's disease reflects the need to consider this diagnosis in a patient of less than 40 years of age presenting with a suspected brain tumor. This may delay the need for invasive diagnostic methods, especially if such methods are not desired by the patient. In the management of suspected neuro-Behcet's disease, initiating steroid therapy and measuring the response is a reasonable option before seeking a definitive diagnosis via brain biopsy. If the response to steroids is minimal then a brain biopsy should be performed.

Approaches in injections for radicular pain: the transforaminal, epidural and transfacet approaches.

Spinal injections must be carried out adhering to very strict conditions. However, these procedures have almost come to be seen as everyday and may be practised under quite questionable conditions. The recent reports of new and extremely serious neurological complications have changed the attitudes of those making referrals as well as the attitudes of the interventional radiologists carrying out these procedures. The range of indications for transforaminal injections has shrunk in favour of epidural injections. Where the transforaminal approach is still used, the needle must be positioned extremely accurately. A prior radioopaque contrast medium injection is essential from a safety perspective. The transforaminal epidural injection via the transfacet approach looks to be a promising alternative that is strictly avascular.

[Arrhythmia and sport]. / Arythmies du sportif.

Sports arrhythmia has gained wide attention with the mediatization of the death of famous sports stars. Sport strongly modifies the structure of the heart with the development of left ventricular hypertrophy which may be difficult to differentiate from that due to doping. Intense training modifies also the resting electrocardiogram with appearance of signs of left ventricular hypertrophy whereas resting sinus bradycardia and atrioventricular conduction disturbances usually reverts upon exertion. Accordingly, arrhythmia may develop ranging from extrasystoles to atrial fibrillation and even sudden death. Recent data suggest that if benign arrhythmia may be the result of the sole intense training and are reversible, malignant ventricular arrhythmia and sudden death mostly occur in unknown structural heart disease. Hypertrophic cardiomyopathy is amongst the most frequent post mortem diagnosis in this situation. Doping is now present in many sports and further threatens the athlete in the safe practice of sport.

Prognostic factors in the management of exacerbation of chronic obstructive pulmonary disease in Kuwait.

OBJECTIVE: To evaluate the clinical presentation and the factors of prognostic importance in the management of exacerbation of chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: One hundred and four patients who were hospitalized because of exacerbation of COPD between 1996 and 2000 were selected for further evaluation. Only patients who fulfilled the American Thoracic Society criteria for diagnosis of COPD were included. The factors examined included age, clinical features, duration of symptoms of exacerbation, severity of underlying disease, comorbid diseases, level of consciousness, previous hospitalization, intubation and assisted ventilation, hypercapnia, degree of acidemia and complications. RESULTS: Seventy-four of 104 (71%) hospitalized patients reviewed met the inclusion criteria for COPD. The mean age was 63.68 +/- 12.6 years. There was a male:female ratio of 3:1. Fifty-eight patients (78%) had a baseline FEV1 <50% before hospitalization and 45 (64%) had previous hospitalization. Comorbid disease was found in 50% of the cases, while 78% had acidemia and 70% hypercapnia. Fourteen (19%) died on admission. Risk factors identified included severity of disease (p < 0.05); presence of comorbid disease (p < 0.01); acidemia (p < 0.0001); hypercapnia (p < 0.0001); previous hospitalization (p < 0.01), and assisted ventilation (p < 0.001). CONCLUSION: This study revealed that the presence of comorbid disease, acidemia, previous hospitalization and assisted ventilation significantly contributed to mortality in patients with exacerbation of COPD.

[Sinus-like tachycardias]. / Tachycardies d'allure sinusale.

Various tachycardias presenting with positive P waves in the standard leads are described in this article. Sinus tachycardia may occur as a normal adaptation reaction to the environment or in the setting of autonomic dysregulation. It may also be mimicked by various arrhythmias which share the earliest depolarisation in the sinus node area. The authors expose a review of these mechanisms.

[Ventricular tachycardia "in salvoes"]. / Les tachycardies ventriculaires en salves.

The term of ventricular tachycardia "in salvoes" describes electrophysiographic appearances of several consecutive ectopic ventricular beats without interposition of sinus rhythm. This is an intermediate arrhythmic state between isolated ventricular extrasystoles and sustained ventricular tachycardia. The generally accepted definition of the term "sustained" implies a duration of over 30 seconds or poor haemodynamic tolerance. Strictly speaking, the term "salvoe" has no precise definition in cardiology. In the 1996 edition of the Petit Robert French dictionary, the term is defined as the simultaneous discharge of guns or successive blasts of canons. The Delaware medical dictionary does not provide a French definition of the term "salvoe". In practice, we use the term tachycardia in salvoes in the same meaning as ventricular tachycardia. Schematically, in clinical practice, two situations may be encountered. In the first case, salvoes of VT are recorded in apparently normal hearts; they are not life-threatening and, though often nearly asymptomatic, they may pose therapeutic problems. In the second case, the arrhythmia occurs in a diseased heart, with a low ejection fraction, in which the essential problem is the vital prognosis.

[Sudden death and semi-automatic defibrillation]. / Mort subite et défibrillation semi-automatique.

While cardiac arrest in hospital poses few immediate management problems, this is not the case outside hospital. For this reason semi-automatic defibrillators are easy to handle devices designed to deliver an early electric shock in the context of usage by non-specialist people following minimum training. These devices have shown a clear improvement in survival compared to the exclusive use of a manual defibrillator by highly trained emergency services, especially in confined areas such as casinos or aircraft, or where a significant number of potential patients are concentrated, such as airports. It is now important to be able to improve public access to defibrillation by various means currently being studied, and probably by relaxing the rules which allow the use of these devices.

Etiologic diagnosis of hepatic lesions in cancer patients. Value of ultrasound and liver function tests.

The purpose of this study was to evaluate the value of a combination of ultrasound (US) and liver function tests (LFT) for determination of the benign or malignant nature of one or more hepatic lesions in cancer patients. A total of 1235 patients with hepatic metastases and 832 patients with benign liver lesions investigated by US-LFT over a 12-year period were analyzed retrospectively. Ultrasound patterns considered indicative of a benign process (cyst, calcification without mass, irregular hyperechoic area without mass effect, small hyperechoic focal lesion as less than 3 cm) or malignancy (peritumoral halo, hypoechoic focal lesion, multiple solid nodules) were associated with LFT results. A US pattern of a benign process associated with normal LFT led to a diagnosis of benign disease with a false negative rate for malignancy of 11.6%. The highest figure corresponded to small hyperechoic nodules, for which the positive predictive value of malignancy (PPVM) depended on the type of primary cancer: 2.1% for breast cancer versus 62.5% for colorectal cancer. A US criterion of malignancy associated with abnormal LFT led to a diagnosis of malignancy (PPV 96.2% to 100%). Overall, the combination of US and LFT had a sensitivity of 80.6% and a specificity of 99.4%. The US-LFT combination correctly determined the benign or malignant nature of 74.5% of all hepatic lesions; the PPV was never less than 96.2% (small and solitary hyperechoic focal lesions were excluded because their PPV for malignancy is too high).

Interstitial laser photocoagulation of osteoid osteomas with use of CT guidance.

PURPOSE: To evaluate interstitial laser photocoagulation (a minimally invasive percutaneous technique of thermal destruction of deep-seated tumors, with low-power laser energy) in local destruction of osteoid osteoma, with computed tomographic (CT) guidance. MATERIALS AND METHODS: Fifteen patients (age range, 8-48 years) with presumed osteoid osteoma were treated with CT-guided interstitial laser photocoagulation of the nidus. A high-power semiconductor diode laser (805 nm) with a 400-microm optical fiber was used. The fiber was introduced into the nidus through an 18-gauge needle. Around the fiber tip, well-defined coagulative necroses from 5 to 9 mm (energy delivery, 400-1,000 J) were obtained. RESULTS: Fourteen patients had complete pain relief, which was apparent within 24 hours in eight patients. One patient had recurrence of pain after 6 weeks. The remaining nidus was treated a second time, with complete relief. Treatment was unsuccessful in one patient, and surgical excision was performed. Daily activities were not restricted after the intervention. All patients were followed up for more than 1 year, with no sign of recurrence. The only notable complication was a mild reflex sympathetic dystrophy of the wrist in one patient. Sclerosis of the nidus was observed 4-6 months after the procedure. CONCLUSION: Percutaneous interstitial laser photocoagulation of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive alternative to traditional surgical and percutaneous ablations.

Hughes syndrome: a common problem in Kuwait hospitals.

The objective was to study antiphospholipid antibody syndrome (APS or Hughes syndrome) in two major teaching hospitals in Kuwait. patients with suspected Hughes syndrome were investigated with tests for anticardiolipin antibodies (aCL) and lupus anticoagulants (LAC) over 1 yr. Diagnosis was considered confirmed if significant levels of either or both antibodies with no obvious cause (primary), or with systemic lupus erythematosus (SLE) or SLE-like illness (including SLE serology) (secondary) were present. Twelve (37.5%; seven females, 58%) primary and 20 (62.5%; 18 females, 90%) secondary Hughes syndrome patients were seen during this period. patients were Kuwaiti, Middle-Eastern and North-African Arabs (29). Filipinos (2) and White (1). None were from the Indian subcontinent. The main presentation was thrombosis in 75% (arterial in 25% and venous in 50%), and recurrent abortions in 50% of married women. Haematological and dermatological manifestations were limited entirely to the secondary variety, seen in 25% and 19%, respectively. Clinical manifestations were severe, leading to death in one, intensive-care management in 31% and with partial or complete warfarin resistance or brittleness in 25%. Neurological/eye and cardiac manifestations were not seen, as these patients may be attending separate speciality hospitals for these diseases in Kuwait. The approximate prevalence of this syndrome was 2.66/1000 admissions in medical wards. Projected to the total referral areas of the two hospitals, an approximate figure of 52 patients/million population/year was obtained. Hughes syndrome was a common problem among Arabs, Filipinos and possibly Whites in Kuwait. Its manifestations were severe, often requiring intensive-care management, and in one case it was fatal. Patients from the Indian subcontinent were conspicuous by their absence, despite the fact that they were well represented in all other rheumatic disease groups. Ethnic and/or geographical factors could be important in this syndrome. To the best of our knowledge, this is the first report of Hughes syndrome from the Middle East.

Indications for hepatic ultrasonography in breast cancer staging and follow-up.

Retrospective analysis of the medical records of 6649 breast cancer patients seen over an 11-year period found 438 patients (6.6%) with liver metastases (LM) and 432 patients (6.5%) with benign liver lesions (BLL). Liver ultrasonography (LUS) and liver function tests had been performed for all patients. LM were the first manifestation of metastatic spread in 20.1% of the 438 patients; median survival was related to the presence (6.7 mo.) or absence (12.2 mo.) of extrahepatic metastases (EHM). Liver function tests were normal in 20.5% of the patients in whom LM were first diagnosed by LUS. Most LM were hypoechoic (70.9%) BLL corresponded to cysts, hemangiomas, calcifications, and focal fatty infiltration. LUS appears indicated for (i) pretherapy disease staging, and in particular for detection of BLL, and (ii) follow-up of patients without EHM for early diagnosis of LM.

Sonographic diagnosis of solitary solid liver nodules in cancer patients.

The purpose of this study was to analyse the sonographic patterns of solitary solid liver lesions in cancer patients and to evaluate the diagnostic accuracy of ultrasound alone and in combination with other techniques (liver function tests, histology). A total of 422 solitary solid liver lesions (SSLL) were diagnosed by ultrasound in cancer patients; 197 lesions were benign and 225 malignant. The predominant aetiology for hypoechoic SSLL (128 cases) was metastasis (112 cases), whereas most hyperechoic SSLL (265 cases) were haemangiomas (155 cases) rather than a metastasis (86 cases). The 29 isoechoic SSLL included 27 metastases and 2 benign lesions. A halo was found to be highly predictive of malignancy (97%-100%). The positive predictive value for malignancy of an SSLL was very high when the results of liver function tests were abnormal (97%-100%). In our experience, histological proof is unnecessary in the majority of liver lesions in cancer patients.

[Giant bronchopyocele. General and radiological characteristics. Apropos of a case]. / Bronchopyocèle géant. Caractères généraux et radiologiques. A propos d'un cas.

A case of giant bronchocele is reported. This lesion is due to a mucus and pus filled dilatation of the bronchial tree proximal to a stenosis. The latter can be either congenital or acquired, or in the context of a diffuse bronchopathy, which can be responsible for a functional stenosis. Both plain radiography and computed tomography findings are diagnostic. The etiology of the abnormality however represents an important problem to be solved. Further, a thoractomy is often necessary, except in those case arising in the context of a diffuse bronchopathy, which usually resolve either spontaneously or following medical treatment.

Very high frequency (13 MHz) ultrasonographic examination of the normal neck: detection of normal lymph nodes and thyroid nodules.

Very high frequency (13 MHz) ultrasonographic examination of the neck successfully visualized one or more normal lymph nodes (weakly echoic oval structures with an echoic central hilum) in 67.6% of 1000 healthy volunteers. Efficacy was not related to recent ear, nose, and throat infection, sex, or age. The longitudinal-transverse diameter ratio was greater than or equal to 2 in 86.2% of cases. No signal was detected with color Doppler imaging. One or more thyroid nodules were also identified in 34.7% of the subjects: the frequency was 44% in women and 42% in subjects over 50 years of age.

Magnetic resonance imaging of von Meyenburg complexes: report of a pathologically documented case.

Von Meyenburg complexes (VMC) are rare malformations of the bile ducts. They are usually associated with adult dominant polycystic disease (ADPCD). Although generally benign, they may give rise to cholangiocarcinomas. Herein, we report the third MR documented case of VMC. The comparative diagnostic value of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) examinations is discussed.

Ultrasound in salivary gland disease.

This text reviews the normal ultrasound (US) anatomy of the salivary glands along with tumoral, lithiasic, and inflammatory pathologies. For salivary gland tumors, US does have limitations (failure to visualize the entire parotid gland, relations with the nerve plexus, in-depth spread of large tumors, false-negative errors of malignancy for small encapsulated tumors). However, US is a simple technique allowing correct identification of the benign nature of a lesion in over 80% of the cases. For lesions under 3 cm in diameter, US is generally the only imaging technique used; for larger lesions, CT or MR is required. Sialolithiasis and inflammatory diseases are being documented by US more and more and the indications for sialography have strongly decreased.

"Clip-stone" filiation within the biliary tract.

A case of cholangitis due to the migration of a metal clip used for surgical cholecystectomy 4 years earlier, is reported. The diagnostic approach and therapeutic options, either endoscopic or surgical are discussed. The use of resorbable clips during the performance of laparoscopic cholecystectomy should avoid this type of complication.

[X-ray computed tomography of duodenal lipoma]. / Scanographie des lipomes duodénaux.

Duodenal lipoma is a rare, often asymptomatic tumor; the circumstances of its discovery have become more frequent as CT examinations are more commonly performed. The merits of a CT examination for this condition is to allow both a positive diagnosis and the follow-up of these fatty tumors which have very few clinical expressions, thus avoiding complementary examinations or even useless laparotomies. The authors describe three cases of incidental discovery of duodenal lipomas.