[Subacute meningococcaemia during adalimumab therapy]. / Méningococcémie subaiguë sous adalimumab.

INTRODUCTION: Subacute or chronic meningococcaemia is an invasive infection by Neisseria meningitidis characterized by fever lasting between a few days (subacute) and a week or more (chronic), cutaneous rash and arthralgia, without meningitis. PATIENTS AND METHODS: A 59-year-old woman was admitted for a fever with cutaneous rash. She had a history of Crohn's disease diagnosed in 2016 and treated with adalimumab for 14 months at a dosage of 40mg/week. For 3 days, she presented fever with a temperature of up to 40°C associated with a non-itchy erythematous-papular eruption on all four limbs, especially the lower limbs. The lesions were mildly painful on palpation. The rest of the clinical examination was unremarkable. The patient did not have arthralgia or neurological symptoms, and in particular, she exhibited no meningeal syndrome. Blood cultures as well as PCR on a skin biopsy specimen confirmed the diagnosis of meningococcaemia. The patient was treated with ceftriaxone 2g/day for 4 days then amoxicillin 12g/day for 4 days. A favourable outcome was quickly achieved, and the condition subsided without sequelae. DISCUSSION: We report the first case of subacute meningococcaemia in a patient treated with anti-TNF alpha therapy. This case concerns the role of biotherapies, and more particularly anti-TNF alpha therapy, in the occurrence of particular infections but also in changes in their clinical presentation and clinical course, as in the present case without arthralgia.

[Normal skin biopsy as a tool for extra-cutaneous disorders]. / Indications extra-cutanées de la biopsie de peau normale.

Biopsies of apparently healthy skin can contribute to the diagnosis of an internal disorder in a patient or in the detection of a potential disease carrier. Herein, we review those diseases for which dermatologists may be asked to perform a biopsy on normal skin where analysis by optical microscopy, immunofluorescence or electronic microscopy may result in diagnosis of an "internal" disease. Diseases for which biopsies are required for cell cultures (e.g. fibroblasts cultures), clonality testing or chromosomal analysis are not discussed here.

Physicians involved in the care of patients with high risk of skin cancer should be trained regarding sun protection measures: evidence from a cross sectional study.

BACKGROUND: Knowledge, regarding sun protection, is essential to change behaviour and to reduce sun exposure of patients at risk for skin cancer. Patient education regarding appropriate or sun protection measures, is a priority to reduce skin cancer incidence. OBJECTIVE: The aim of this study was to evaluate the knowledge about sun protection and the recommendations given in a population of non-dermatologists physicians involved in the care of patients at high risk of skin cancer. MATERIALS AND METHODS: This study is a cross-sectional study. Physicians were e-mailed an anonymous questionnaire evaluating the knowledge about risk factors for skin cancer, sun protection and about the role of the physician in providing sun protection recommendations. RESULTS: Of the responders, 71.4% considered that the risk of skin cancer of their patients was increased when compared with the general population. All the responders knew that UV-radiations can contribute to induce skin cancers and 71.4% of them declared having adequate knowledge about sun protection measures. A proportion of 64.2% of them declared that they were able to give sun protection advices: using sunscreens (97.8%), wearing covering clothes (95.5%), performing regular medical skin examination (91.1%), to avoid direct sunlight exposure (77.8%), avoiding outdoor activities in the hottest midday hours (73.3%) and practising progressive exposure (44.4%). CONCLUSION: Non-dermatologist physicians reported a correct knowledge of UV-induced skin cancer risk factors. The majority of responders displayed adequate knowledge of sun protection measures and declared providing patients with sun protection recommendation on a regular basis. Several errors persisted.

[Incidence, risk factors and skin manifestations of post-thrombotic syndrome: a four-year follow-up of patients included in the EDITH study]. / Incidence, facteurs de risque et signes cutanés de la maladie post-thrombotique : suivi à quatre ans des patients inclus dans l'étude EDITH.

PURPOSE: Despite appropriate therapy 10 to 100% of patients with deep vein thrombosis (DVT) of the lower limbs will develop post-thrombotic syndrome (PTS). The aim of this study was to evaluate the incidence of PTS in the EDITH cohort and to estimate the association between initial patients' characteristics and the risk of development of PTS. METHODS: One hundred and eighty patients included in the EDITH study for a first event of DVT of the lower limbs without clinical signs of venous insufficiency were recalled 4 years after their initial thrombotic event. PTS was diagnosed according to the Villalta score. RESULTS: Ninety-five patients (45 men, mean age 50.7 ± 16.9 years) were evaluated for PTS. Among them, 28.4% (95% CI 19.3-37.5) developed PTS but none had severe PTS. The most frequent clinical signs of PTS were varicose veins (59%), corona phlebectatica (48%), swelling leg (30%) and pigmented dermatitis (26%). No single risk factor was associated with PTS development (age, sex, BMI thrombophilia, etiology, localization, recurrence, symptomatic DVT and familial history of DVT). CONCLUSION: PTS is a frequent disease. However, lack of uniformity of diagnosis criteria in the different studies does not make possible the estimation of PTS risk factors.

[Hand-foot syndrome: A new side effect of erlotinib]. / Syndrome mains-pieds : nouvel effet secondaire de l'erlotinib.

BACKGROUND: Erlotinib (Tarceva) belongs to the family of epidermal growth receptor factor (EGFR) inhibitors. Used in the treatment of some cancers, it is responsible for several cutaneous side effects. We report a case of hand-foot syndrome, which has not previously been described with this drug to our knowledge. PATIENTS AND METHODS: A 65-year-old patient was given erlotinib for lung cancer and after the first month of treatment, he developed severe hand-foot syndrome. DISCUSSION: Hand-foot syndrome consists of abrupt bilateral and painful acral erythema associated with dysesthesia. It is a dose-dependent side effect of certain cytostatic drugs. It may sometimes require withdrawal of the causative drug. Care must be taken to identify the early signs of hand-foot syndrome in patients treated with erlotinib.

Eczematous dermatosis and thrombocytosis induced by efalizumab: two new side effects.

Efalizumab was authorized to be put on the market in France starting July 21, 2005. Its efficacy and tolerance profile in plaque psoriasis at a dose of 1 mg kg(-1) weekly in a subcutaneous injection have been studied in phase III trials. At the current moment, more than 3,500 patients have been included in clinical trials. Flu-like symptoms (fever, chills, headaches, nausea, vomiting, myalgia) are the most frequent adverse events. On the skin, a localized papular rash or the aggravation of the psoriasis in an edematous or even pustular form are the two most regularly observed complications. At the biological level, hyperlymphocytosis and a temporary increase in alkaline phosphatases without clinical consequences are the most frequent anomalies. We report 2 adverse events under efalizumab that to our knowledge have never been described: a case of an eczematous rash and a case of thrombocytosis.

[Bullous pemphigoid sparing acquired lymphedema]. / Une pemphigoïde bulleuse épargnant un lymphoedème acquis.

BACKGROUND: Bullous pemphigoid is an autoimmune disease, common in the elderly and generally of symmetrical and systemic localization. We report a case with sparing of the lower limb and acquired lymphedema secondary to lymph node surgery. CASE REPORT: A 74-year-old woman was hospitalized for a bullous eruption. The left lower limb was completely spared and was unaffected by pruritus. Acquired lymphedema was seen in this limb secondary to lymph node surgery. Standard histopathology tests confirmed the diagnosis of bullous pemphigoid with subepidermal blistering, while a direct immunofluorescence antibody test showed linear binding of IgG and C3 throughout the basement membrane. Western blotting revealed anti-BPAg2 antibodies. Skin biopsy on the lymphedema spared by the disease revealed no inflammatory infiltrate in the dermis. However, linear binding of anti-IgG and anti-C3 autoantibodies was observed. DISCUSSION: Other cases of localized bullous pemphigoid appearing on body areas treated by UV or radiotherapy have been reported. Cases of bullous pemphigoid with predilection for areas of lymphedema have also been previously described: the hypothesis has been advanced of reduced lymphatic flow, with increased antigen-antibody contact enabling better binding. Our case is original and, given the protective nature of this lymphedema, suggests two hypotheses. There could be deterioration of local cellular immunity, with decreased activation of T lymphocytes. They could also be impairment of nervous conduction, as suggested by the absence of pruritus, with partial or total inhibition of neurogenic inflammation.

Hyperhomocysteinemia and low B vitamin levels are independently associated with venous thromboembolism: results from the EDITH study: a hospital-based case-control study.

BACKGROUND: Moderate hyperhomocysteinemia and B vitamins deficiency are thought to be risk factors for venous thromboembolism (VTE). The causality and independence of those associations are still questioned. METHODS: We measured fasting serum total homocysteine, folates, and vitamin B12 levels as well as 5,10-methylenetetrahydrofolate reductase (MTHFR) C677T genotypes in 467 patients hospitalized with a first well-documented deep vein thrombosis and/or pulmonary embolism not related to a major acquired risk factor and 467 controls matched for gender and age. RESULTS: Mild hyperhomocysteinemia, low serum folates, and vitamin B12 were associated with VTE independently of each other. In multivariate analysis, odds ratios (OR) (95% CI) for VTE associated with mild hyperhomocysteinemia (>15 micromol L(-1)), low serum folates (< or = 4.9 nmol L(-1)), and vitamin B12 (< or = 253 pmol L(-1)) were 1.48 (1.05-2.08), 3.14 (1.35-7.32) and 1.42 (1.03-1.98), respectively. An MTHFRC677T genotype was not significantly associated with VTE; OR (95% CI): 1.13 (0.70-1.81) CONCLUSIONS: The current data provides further knowledge in the complex relationship between hyperhomocysteinemia, low vitamin levels, and VTE.

Primary Gougerot-Sjögren syndrome: a dermatological approach.

Gougerot-Sjögren syndrome (GSS) is a chronic heterogeneous non-organ-specific autoimmune disease, encompassing a wide spectrum of clinical manifestations. It is characterized by a lymphocytic infiltration of the exocrine glands, also called epitheliitis, resulting in xerostomia and keratoconjunctivitis sicca. The skin can also be involved; for example, xerosis is a consequence of epitheliitis. Dermatological consequences of polyclonal reactivity are vasculitis and manifestations of B-cell proliferation vary from plasma cell infiltrates to B-cell lymphoma.

[Mycobacterium marinum tenosynovitis of the abductors]. / Ténosynovite des fléchisseurs à Mycobacterium marinum.

INTRODUCTION: Infection with Mycobacterium marinum is rare and usually produces cutaneous lesions. We report here two cases of tenosynovitis of abductor muscles. CASE: The first case presented isolated involvement of the abductors of the left thumb, and the second the abductors of the middle finger. In both cases, the bacteriological examinations found M. marinum. Antibiotic therapy for three months with rifampin and clarithromycin cured the infection. DISCUSSION: These cases of tenosynovitis followed deep inoculation. A mycobacterial infection should be considered in cases of synovitis, especially when limited to an area of the hand in patients without other rheumatic disorders.

Intralesional therapy with anti-CD20 monoclonal antibody rituximab: local and systemic efficacy in primary cutaneous B-cell lymphoma.

Rituximab (MabThera, Roche) is a chimeric monoclonal antibody directed against the CD20 antigen. Its efficacy and safety were first demonstrated in the treatment of systemic B-cell lymphomas. We report the use of intralesional injections of rituximab into some but not all cutaneous lesions in a patient with multiple primary cutaneous follicular centre B-cell lymphoma. This treatment resulted in tumour regression, even of the lesions that had not been injected. We therefore hypothesize that there is systemic diffusion of rituximab from injected sites despite the low doses injected locally, or the induction of a specific antitumour immune response acting systemically.

Cutaneous manifestations of primary Sjögren's syndrome are underestimated.

The association of kerato-conjunctivitis sicca and xerostomia has been termed Sjogren's syndrome (SS). Although this disease is referred to as a non-organ-specific autoimmune condition, the vast majority of the deleterious effects of primary SS are restricted to the exocrine glands. Among them, the lacrymal and salivary glands are at the foreground, owing to the severity of the objective consequences and the importance of the subjective manifestations. As a result, cutaneous manifestations are minimized, albeit relatively common. We have carefully analyzed the literature to draw up an inventory of the possible skin complications of this syndrome. In addition to xerosis and epidermal IgG deposits, they include vasculitis and cutaneous B cell lymphoma. Alopecia, vitiligo and papular lesions have also been reported to be associated with primary SS.

[Atopic dermatitis: which are the diagnostic criteria used in medical literature?]. / Dermatite atopique: quels sont les critères diagnostiques utilisés dans les articles scientifiques?

INTRODUCTION: Diagnosis of atopic dermatitis currently relies on diagnostic criteria scales developed by Hanifin and Rafka in 1980 and by the "United Kingdom Working party" in 1994. Some authors have proposed: "AEDS" [sM1] and "Atopiform Dermatitis", which has led to the distinction between different sub-populations and the exclusion of certain diseases from the diagnosis of atopic dermatitis. The aim of our study was to collect the criteria retained in the scientific medical literature during the year 2002 for the definition of atopic dermatitis and to try to understand not only the interest but also the questions that the various definitions lead to. METHOD: A PubMed research was launched with the key word "atopic dermatitis" from January to September of 2002. All the scientific articles either in French or in English were studied. RESULTS: Hanifin and Rafka's criteria were selected in 44 p. 100 of the scientific articles, and the "United Kingdom Working Party" criteria in 12 p. 100. Personal definitions were used in 21 p. 100 of the articles; these were based on the level of total and specific IgE or on personal clinical criteria. For twenty-three p. 100 of the authors, the definition of atopic dermatitis was not specified. DISCUSSION: There was not just one definition of atopic dermatitis. This may affect the interpretation of diagnostic or therapeutic papers concerning the disease, because there has been no proof that these definitions cover the same population of patients.