Diagnostic des maladies infectieuses: place des "point of care tests" (POCT) [Use of POCT (point of care tests) in the diagnosis of infectious diseases]

Les POCT (point of care tests) ont un grand potentiel d'utilisation en médecine infectieuse ambulatoire grâce à leur rapidité d'exécution, leur impact sur l'administration d'antibiotiques et sur le diagnostic de certaines maladies transmissibles. Certains tests sont utilisés depuis plusieurs années (détection de Streptococcus pyogenes lors d'angine, anticorps anti-VIH, antigène urinaire de S. pneumoniae, antigène de Plasmodium falciparum). De nouvelles indications concernent les infections respiratoires, les diarrhées infantiles (rotavirus, E. coli entérohémorragique) et les infections sexuellement transmissibles. Des POCT, basés sur la détection d'acides nucléiques, viennent d'être introduits (streptocoque du groupe B chez la femme enceinte avant l'accouchement et la détection du portage de staphylocoque doré résistant à la méticilline). POCT have a great potential in ambulatory infectious diseases diagnosis, due to their impact on antibiotic administration and on communicable diseases prevention. Some are in use for long (S. pyogenes antigen, HIV antibodies) or short time (S. pneumoniae antigen, P. falciparum). The additional major indications will be community-acquired lower respiratory tract infections, infectious diarrhoea in children (rotavirus, enterotoxigenic E. coli), and hopefully sexually transmitted infections. Easy to use, these tests based on antigen-antibody reaction allow a rapid diagnosis in less than one hour; the new generation of POCT relying on nucleic acid detection are just introduced in practice (detection of GBS in pregnant women, carriage of MRSA), and will be extended to many pathogens

Fatal tolperisone poisoning: Autopsy and toxicology findings in three suicide cases.

Tolperisone (Mydocalm(®)) is a centrally acting muscle relaxant with few sedative side effects that is used for the treatment of chronic pain conditions. We describe three cases of suicidal tolperisone poisoning in three healthy young subjects in the years 2006, 2008 and 2009. In all cases, macroscopic and microscopic autopsy findings did not reveal the cause of death. Systematic toxicological analysis (STA) including immunological tests, screening for volatile substances and blood, urine and gastric content screening by GC-MS and HPLC-DAD demonstrated the presence of tolperisone in all cases. In addition to tolperisone, only the analgesics paracetamol (acetaminophen), ibuprofen and naproxen could be detected. The blood ethanol concentrations were all lower than 0.10g/kg. Tolperisone was extracted by liquid-liquid extraction using n-chlorobutane as the extraction solvent. The quantification was performed by GC-NPD analysis of blood, urine and gastric content. Tolperisone concentrations of 7.0mg/l, 14mg/l and 19mg/l were found in the blood of the deceased. In the absence of other autopsy findings, the deaths in these three cases were finally explained as a result of lethal tolperisone ingestion. To the best of our knowledge, these three cases are the first reported cases of suicidal tolperisone poisonings.

Procalcitonin and C-reactive protein in pericardial fluid for postmortem diagnosis of sepsis.

The aim of this study was to investigate the presence and concentrations of procalcitonin and C-reactive protein in pericardial fluid and compare these levels to those found in the postmortem serum obtained from the femoral blood. Two groups were formed, a sepsis-related fatalities group and a control group. Postmortem native CT scans, autopsies, histology, neuropathology and toxicology as well as other postmortem biochemistry investigations were performed in all cases. Pericardial fluid procalcitonin levels were significantly different between the cases of sepsis-related fatalities and those of the control group. Postmortem serum procalcitonin levels below the detection limit were also reflected in undetectable pericardial fluid levels. Similarly, a large increase in postmortem serum procalcitonin levels was reflected in a large increase of procalcitonin pericardial fluid levels. Based on these findings, pericardial fluid could be an alternative to postmortem serum for the determination of procalcitonin levels in cases where postmortem serum is not available and measurements of procalcitonin are required to circumstantiate the pathogenesis of death.

Le pyoderma gangrenosum: pathologie rare ou diagnostic omis [Pyoderma gangrenosum: a rare pathology or an omitted diagnosis?]

Pyoderma gangrenosum is a rare pathology of uncertain etiology. It is an inflammatory dermatosis that causes cutaneous necrosis with a characteristically rapid evolution. No precise diagnosis criteria has been established and pyoderma gangrenosum remains an exclusion diagnosis. In 40 to 50% of the cases, the evolution of pyoderma gangrenosum can be worsened by a nonspecific external stimulus such as a trauma or a surgery. This phenomenon, called pathergy, conduces to avoid any surgical excision of the lesion. However, the diagnosis is often omitted and the rapid evolution of the cutaneous necrosis forces the surgeon to perform a surgical debridement of the wound. It causes a pejoration of the lesion. It can have disastrous consequences. We present here three different case reports.

Detection of coronary thrombosis after multi-phase postmortem CT-angiography.

The aim of this study was to compare postmortem angiography-based, autopsy-based and histology-based diagnoses of acute coronary thrombosis in a series of medicolegal cases that underwent postmortem angiographies according to multiphase CT-angiography protocol. Our study included 150 medicolegal cases. All cases underwent native CT-scan, postmortem angiography, complete conventional autopsy and histological examination of the main organs and coronary arteries. In 10 out of the 150 investigated cases, postmortem angiographies revealed coronary arterial luminal filling defects and the absence of collateral vessels, suggesting acute coronary thromboses. Radiological findings were confirmed by autopsy and histological examinations in all cases. In 40 out of 150 cases, angiograms revealed complete or incomplete coronary arterial luminal filling defects and the presence of collateral vessels. Histological examinations did not reveal free-floating or non-adherent thrombi in the coronary arteries in any of these cases. Though postmortem angiography examination has not been well-established for the diagnosis of acute coronary thrombosis, luminal filling defects in coronary arteries suggesting acute thromboses can be observed through angiography and subsequently confirmed by autopsy and histological examinations.

Video-assisted thoracic surgery diagnosis of thoracic spinal tuberculosis.

Tuberculous spondylitis is rare in economically well-developed countries. MRI is the most sensitive radiologic method of diagnosis. CT-guided fine needle aspiration can be an appropriate method for obtaining samples for culture, with positive cultures in 25 to 89% of cases. However, it can take >6 weeks for specimens to grow, and it is essential to have adequate culture and sensitivity studies for the diagnosis and treatment of mycobacterial diseases. We propose a minimally invasive diagnostic approach that ensures that adequate surgical specimens are obtained prior to initiating treatment.

Le cancer est-il une maladie nouvelle? A propos du diagnostic des maladies tumorales dans le De Medicina de Celse [Is cancer a new disease? Apropos of diagnosis of tumor diseases in De Medicina by Celsus]

Cancer is a particularly common disease in modern societies. Moreover, epidemiology considers it typical of contemporary pathology. Nevertheless, the abundant ancient literature-in the De Medicina by Celsus, among others-leads us to believe that numerous benign and malignant tumours were observed if not identified as such. Hence, it is possible that both the change in medical conceptualization and the real increase in the prevalence are responsible for the actual importance of cancer

The correct name, species diagnosis, and distribution of the Sicilian shrew

New karyological and morphological data show that Sicily, the Egadi Islands, Malta and Gozo are (ore were) inhabited by a particular species of Crocidura, for which the name Crocidura sicula Miller, 1901 is available. The species is briefly diagnosed and described and a new key to the European species of Crocidura is presented

Postmortem diagnosis of hypothermia.

The identification of hypothermia as the cause of death has always been somewhat problematic in forensic pathology because of unspecific, inconstant, or even negative macroscopic and microscopic findings. Though the simultaneous presence of frost erythema, Wischnewski spots, hemorrhages into the synovial membrane, bloody discoloration of synovial fluid of the knee, and basal vacuolization of the renal tubular epithelial cells has been indicated as strongly supportive of fatal hypothermia, their absence does not allow the diagnosis of hypothermia to be ruled out. Postmortem biochemical investigations are valuable in detecting adaptation responses to cold stress and metabolic changes that occur following cold exposure. However, ethanol intoxication prevents appearance of adaptation responses to cold, rendering the diagnosis less obvious. Immunohistochemistry, postmortem imaging, and molecular pathology have shown promising results, although at present, they do not provide pathognomonic signs of fatal hypothermia. The aim of this article is to present a review of the literature covering the significance of different postmortem investigations that are associated with hypothermia fatalities.

Delay in diagnosis of eosinophilic esophagitis increases risk for stricture formation in a time-dependent manner.

BACKGROUND & AIMS: Development of strictures is a major concern for patients with eosinophilic esophagitis (EoE). At diagnosis, EoE can present with an inflammatory phenotype (characterized by whitish exudates, furrows, and edema), a stricturing phenotype (characterized by rings and stenosis), or a combination of these. Little is known about progression of stricture formation; we evaluated stricture development over time in the absence of treatment and investigated risk factors for stricture formation. METHODS: We performed a retrospective study using the Swiss EoE Database, collecting data on 200 patients with symptomatic EoE (153 men; mean age at diagnosis, 39 ± 15 years old). Stricture severity was graded based on the degree of difficulty associated with passing of the standard adult endoscope. RESULTS: The median delay in diagnosis of EoE was 6 years (interquartile range, 2-12 years). With increasing duration of delay in diagnosis, the prevalence of fibrotic features of EoE, based on endoscopy, increased from 46.5% (diagnostic delay, 0-2 years) to 87.5% (diagnostic delay, >20 years; P = .020). Similarly, the prevalence of esophageal strictures increased with duration of diagnostic delay, from 17.2% (diagnostic delay, 0-2 years) to 70.8% (diagnostic delay, >20 years; P < .001). Diagnostic delay was the only risk factor for strictures at the time of EoE diagnosis (odds ratio = 1.08; 95% confidence interval: 1.040-1.122; P < .001). CONCLUSIONS: The prevalence of esophageal strictures correlates with the duration of untreated disease. These findings indicate the need to minimize delay in diagnosis of EoE.

Preimplantation genetic diagnosis (PGD) for HLA typing: bases for setting up an open international collaboration when PGD is not available.

In severe forms of Diamond-Blackfan anemia, preimplantation genetic diagnosis (PGD) of histocompatibility leukocyte antigen-compatible embryos for enabling the next sibling in the family to be a stem-cell transplantation donor constitutes the sole lasting cure capable of terminating the enduring need for iterative transfusions. We report here an open collaboration between two renowned institutions to provide a family desiring this treatment even though they resided where the preimplantation genetic diagnosis procedure is banned.

ESCMID* guideline for the diagnosis and management of Candida diseases 2012: patients with HIV infection or AIDS.

Mucosal candidiasis is frequent in immunocompromised HIV-infected highly active antiretroviral (HAART) naive patients or those who have failed therapy. Mucosal candidiasis is a marker of progressive immune deficiency. Because of the frequently marked and prompt immune reconstitution induced by HAART, there is no recommendation for primary antifungal prophylaxis of mucosal candidiasis in the HIV setting in Europe, although it has been evidenced as effective in the pre-HAART era. Fluconazole remains the first line of therapy for both oropharyngeal candidiasis and oesophageal candidiasis and should be preferred to itraconazole oral solution (or capsules when not available) due to fewer side effects. For patients who still present with fluconazole-refractory mucosal candidiasis, oral treatment with any other azole should be preferred based on precise Candida species identification and susceptibility testing results in addition to the optimization of HAART when feasible. For vaginal candidiasis, topical therapy is preferred.

Nouveautés dans la physiopathologie, le diagnostic et le traitement de la douleur neuropathique [New concepts in the pathophysiology, diagnosis and treatment of neuropathic pain].

We here summarize five articles bringing new advances in our knowledge on neuropathic pain and put them into perspective with our current understanding. The first uses a mechanism-based approach with a capsaicin test to stratify patients suffering from painful diabetic neuropathy before starting a topical clonidine treatment. The second reviews disinhibition as a critical mechanism and a promising target for chronic pain. The third evokes neuroglial interactions and its implication regarding the interplay between injuries in childhood and hypersensitivity in adulthood. The last articles remind us that interventional therapies, not always very invasive, have a future potential in the therapy of frequent conditions such as head pain disorders.

Chirurgie thoracique majeure et dénutrition préopératoire: rationnel, diagnostic et prise en charge [Thoracic surgery and underfeeding scientific evidences, diagnosis and treatment]

Underfeeding causes a significant increase of postoperative complications, particularly respiratory and infectious complications. Thoracic surgery is frequently required in patients suffering wasting diseases (cancer, COPD, cystic fibrosis), which increase the risk of malnutrition. The most important risk factors are preoperative hypoalbuminemia and BMI < 20. The deleterious effects of underfeeding may be corrected by a preoperative nutritional support for 7 to 15 days using oral supplements or enteral feeding: respiratory muscle strength is improved, immunity is restored, and overall complications are reduced. Therefore preoperative diagnosis of underfeeding is of utmost importance. In case of emergency surgery, the nutritional assessment on admission enables the introduction of early postoperative artificial feeding.