Ponction biopsie medullaire [Bone marrow aspiration and biopsy]

Le diagnostic final des pathologies impliquant le système hématopoïétique tel que les leucémies, pancytopénies inexpliquées ou autres désordres médullaires, requiert une ponction biopsie de moelle. Cette procédure relativement invasive doit être maîtrisée non seulement par l'hématologue, mais également par l'interniste. Il est crucial d'en connaître les indications et contre-indications et de pouvoir prévenir les complications par une bonne connaissance de celles-ci. Cet article revoit ces différents éléments et apporte les détails pratiques de la procédure ainsi que le matériel nécessaire. The definitive diagnosis of several hematological diseases, as for instance leukaemias, unexplained pancytopenias and other bone marrow disorders, requires a bone marrow aspiration and biopsy. Not only haematologists, but also internists, need to master this rather invasive procedure. The knowledge of indications, contra-indications, potential complications and their prevention of its complications is of utmost importance. This article reviews these topics about bone marrow biopsy, giving some practical advices on this procedure

La maladie de Wilson: un caméléon clinique auquel il faut penser [A primer on Wilson disease for the general practitioner].

Wilson disease (WD) is an inherited disorder of hepatic copper excretion leading to toxic accumulation of copper in the liver as well as the brain, cornea, and other organs. The defect is due to mutations of the copper-transporting ATPase ATP7B. Clinical manifestations are highly variable and comprise acute liver failure, chronic hepatitis and cirrhosis as well as neurological or psychiatric symptoms. The Kayser-Fleischer corneal ring is pathognomonic but absent in about 50% of patients with hepatic manifestations alone. A high index of suspicion in clinically compatible situations is key, with a combination of laboratory tests allowing the diagnosis of WD. Treatment is based on the use of chelating agents, D-penicillamine or trientine. Liver transplantation should be considered for patients with acute liver failure or advanced cirrhosis.

The role of laparoscopic biopsies in lumbar spondylodiscitis.

The infection of an intervertebral disk is a serious condition. The diagnosis often is elusive and difficult to make. It is imperative to have appropriate microbiologic specimens before the initiation of treatment. We report the case of a 51-year-old woman with lumbar spondylodiscitis caused by infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging (MRI) scan confirmed the diagnosis, but computed tomography (CT)-guided fine-needle biopsy did not yield adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. We believe that this minimally invasive procedure should be performed when CT-guided fine-needle biopsy fails to yield a microbiologic diagnosis in spondylodiscitis.

American Cancer Society guideline for the early detection of prostate cancer: update 2010.

In 2009, the American Cancer Society (ACS) Prostate Cancer Advisory Committee began the process of a complete update of recommendations for early prostate cancer detection. A series of systematic evidence reviews was conducted focusing on evidence related to the early detection of prostate cancer, test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening. The results of the systematic reviews were evaluated by the ACS Prostate Cancer Advisory Committee, and deliberations about the evidence occurred at committee meetings and during conference calls. On the basis of the evidence and a consensus process, the Prostate Cancer Advisory Committee developed the guideline, and a writing committee drafted a guideline document that was circulated to the entire committee for review and revision. The document was then circulated to peer reviewers for feedback, and finally to the ACS Mission Outcomes Committee and the ACS Board of Directors for approval. The ACS recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested.

The role of laparoscopic biopsies in lumbar spondylodiscitis.

Infection of an intervertebral disk is a serious condition. Diagnosis often is elusive and difficult. It is imperative to obtain appropriate microbiological specimens before initiation of treatment. The authors describe a 51-year-old woman with lumbar spondylodiscitis that was because of infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging confirmed the diagnosis, but computed tomography-guided fine needle biopsy did not provide adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of Propionibacterium acnes infection. The authors believe that this minimally invasive procedure should be performed when computed tomography-guided fine needle biopsy does not provide a microbiologic diagnosis in spondylodiscitis.

Acute flare induced by the calcific tendonitis of the rotator cuff: inhibition of IL-1 a potential therapeutic target?

Introduction: Calcific tendonitis of rotator cuff is observed on plainradiographs in 10% of adults, but remains asymptomatic in half thesecases. Sometimes, these calcifications induce acute flares withmassive inflammation similar to gout or CPPD crisis. Analgesics/anti-inflammatory medications are usually not sufficient to controlssymptoms in these situations. Local steroid infiltration with or withoutremoval of the calcific deposition with a needle aspiration may beuseful. A new approach could be IL-1 inhibitors. Indeed, basic calciumphosphate crystals are capable of stimulating the release of activeIL-1β in vitro. These crystals trigger IL-1β release, in an analogousmanner to MSU crystals in acute gout, suggesting that IL-1β blockademay be clinically useful.Case presentation: This report describes a 70-year old woman withacute rest pain of the right shoulder since 48 hours. On examination,we found massive limitations of active and passive movements. Thepatient evaluated, on the visual scale, her symptoms at 10/10 the nightand 5/10 the day. The radiography and showed a rounded, 8 mmcalcification in the subscapularis tendon. The ultrasound aspectrevealed a heterogeneous calcification partially non solid, surroundedby massive inflammation on Doppler. C-reactive protein anderythrocyte sedimentation rate were high (74 mg/ml, 54 mm/hour).The patient received subcutaneous injections of anakinra: 100 mgdaily for 3 days (D1-D3). We evaluated the patient in our consult at dayD1, D2, D3, D7, D16 and by phone at D70.This treatment rapidly relieved the inflammatory symptoms (within afew hours with no relapse). The mobility of the shoulder, the biologicsparameters improved and the size of the calcification as well thedegree of inflammation regressed on ultrasound after 3 days.Conclusion: This is the first report of a woman with an acute flareinduced by calcific tendonitis who received anakinra. IL-1 inhibitionmay be a therapeutic target in calcific tendonitis. To analyse thisresponse more precisely and elaborate definitive conclusions, aprospective pilot study is on-going in our ambulatory institute.

Benign Intrapulmonary Schwannoma: Aspect on F-18 Fluorodeoxyglucose PET/CT.

A 75-year-old man, with no significant symptoms, was referred after the incidental finding of a left hilar pulmonary mass of 30 × 30 × 50 mm on a chest CT. F-18 fluorodeoxyglucose (FDG) PET/CT demonstrated a heterogeneous, moderate radiotracer uptake in the mass (SUV 3.5 g/mL). Bronchoscopy revealed a discrete extrinsic compression of the superior bronchus without endobronchial lesion. Endobronchial fine-needle biopsies could not deliver a final diagnosis. The patient underwent upper lobectomy by thoracotomy. Histopathology revealed a benign intrapulmonary schwannoma. Although rare, intermediate FDG uptake in the settings of a pulmonary mass should include schwannoma in the differential diagnosis.

Molecular typing of mycobacteria isolated from extrapulmonary tuberculosis patients at Debre Birhan Referral Hospital, central Ethiopia.

Abstract Background: Extrapulmonary tuberculosis (EPTB) constitutes about 10% to 20% of all cases of tuberculosis in immunocompetent patients and more than 50% of the cases in HIV-positive individuals worldwide. Little information is available on the clonal diversity of Mycobacterium species in Ethiopia from EPTB. Methods: This study was carried out on smear-negative EPTB patients to molecularly characterize Mycobacterium tuberculosis complex strains. A questionnaire, smear staining, culture, deletion typing, and spoligotyping were employed. Results: The proportional distribution of EPTB and isolates did not vary substantially (p > 0.05) amongst the socio-demographic parameters considered in the current investigation. Out of 98 fine needle aspirates processed for culture, 36.7% (36/98) were positive for mycobacterial growth. Further speciation of those culture-positive isolates showed that 88.9% were M. tuberculosis and the remaining could be non-tuberculous mycobacterial species. Spoligotyping revealed 16 clusters out of which 2 were new to the SITVIT database. The most dominant spoligotypes were SIT54, SIT53, and SIT149 in decreasing order. SIT54, SIT134, SIT173, SIT345, SIT357, SIT926, SIT91088, and SIT1580 were reported for the first time in Ethiopia. The family with the highest frequency identified was M. tuberculosis family T1, followed by family 33. Most of the strains belonged to Euro-American (61.4%) and Indo-Oceanic (36.3%) lineages. Conclusions: The present study shows the importance of M. tuberculosis as a major cause of EPTB in the study area. Moreover, the majority of isolates of M. tuberculosis were found in clusters, suggesting the possibility of the existence of recent transmission. This warrants strengthening of the control programs for EPTB in the study area.

Oral chloramphenicol therapy for multiple liver abscesses in hyperimmunoglobulinemia E syndrome.

In a patient with Hyper-IgE-syndrome multiple liver abscesses developed in spite of prophylactic treatment with trimethoprim and sulfamethoxazol. Ultrasound confirmed the clinical diagnosis and percutaneous needle aspiration under ultrasonographic guidance and culture of the aspirated pus allowed specific antibiotic treatment by oral chloramphenicol alone without surgical drainage. The isolated Staph.aureus strain was resistant to trimethoprim and sulfamethoxazol.

Traitement par thoracoscopie du pneumothorax récidivant [Thoracoscopic treatment of recurrent pneumothorax].

Spontaneous pneumothorax (PNO) is usually due to rupture of a small subpleural bleb into the pleural cavity and affects mainly young men. After simple drainage, recurrence occurs in about 50% of cases. The risk of recurrence increases after each new PNO. Secondary PNO complicates an underlying pulmonary disease, especially chronic obstructive pulmonary disease with emphysema. A new form of secondary PNO has emerged in the recent years in AIDS patients with pneumocystis carinii pneumonia. We have shifted to a thoracoscopic therapy of PNO since May 1991. 25 PNO in 24 patients (1 bilateral) have been treated since that time up to April 1993. 19 PNO were primary, whereas 6 were secondary, included 3 iatrogenic PNO. Resection of the leaking parenchymal area was performed in 20 patients, and parietal partial pleurectomy was done in 20 cases. In the remaining cases, fibrin glue was applied on the lesion and in 3 cases, chemical pleurodesis was attempted using silver nitrate or talc. 1 AIDS patient died of ARDS. 3 patients had recurrent PNO and had thoracotomy without complication. 21 patients did well. Partial PNO recurred in one of them 4 months later, and was treated by simple needle aspiration. Thoracoscopy is a useful method to treat recurrent or persistent spontaneous PNO. After only 25 cases, our success rate in primary PNO is 90%. There should be a learning curve. On the basis of our experience, we believe that recognition of the lesion and its resection as well as apical parietal pleurectomy are necessary to obtain good results and a low recurrence rate.

Mini invasive skeletal muscle biopsy technique with a tri-axial end cut needle.

OBJECTIVE: Skeletal Muscle Biopsy is a minor surgical procedure for the diagnosis of different neuromuscular pathological conditions and has recently gained popularity also in the research field of age-related muscular modifications and sarcopenia. Few studies focused on the application of mini-invasive muscular biopsy in both normal and pathological conditions. The aim of our study was to describe a mini invasive ultrasound-guided skeletal muscular biopsy technique in complete spinal cord injured (SCI) patients and healthy controls with a tri-axial end-cut needle. PATIENTS AND METHODS: Skeletal muscle biopsies were collected from 6 chronic SCI patients and 3 healthy controls vastus lateralis muscle with a tri-axial end cut needle (Biopince© - Angiotech). Muscle samples were stained for ATPase to determine fibers composition, moreover, gene expression of cyclooxygenase-1 (COX-1) and prostaglandin E2 receptor has been analyzed by Real Time RT-PCR. RESULTS: All the procedures were perfomed easily without failures and complications. Control tissue was macroscopically thicker than SCI one. Control specimen displayed an equal distribution of type I and type II fibers, while SCI sample displayed a prevalence of type II fibers SCI specimen displayed a significant reduction in COX-1 gene expression. This mini-invasive approach was easy, accurate and with low complication rate in performing skeletal muscle biopsy in both SCI patients and controls. CONCLUSIONS: This technique could be useful in conditions in which the overall quantity of specimen required is small like for molecular biology analysis. For histological diagnostic purposes and/or conditions in which the original tissue is already pathologically modified, this technique should be integrated with more invasive techniques.

Transthoracic adrenal biopsy procedure using artificial carbon dioxide pneumothorax as outpatient procedure.

Many routes have been described for percutaneous adrenal gland biopsy. They require either a complex non-axial path or a long hydrodissection or even pass through an organ thereby increasing complications. We describe here an approach using an artificially-induced carbon dioxide (CO2) pneumothorax, performed as an outpatient procedure in a 57-year-old woman. Under local anaesthesia, 200 ml of CO2 was injected in the pleural space through a Veress needle under computed tomography fluoroscopy, to clear the lung parenchyma from the biopsy route. Using this technique, transthoracic adrenal biopsy can be performed under simple local anaesthesia as an safely outpatient procedure.

Interpretation of needle biopsies of the kidney for investigation of renal masses.

The development of new therapeutic options for renal tumors has lead to the need of a pretherapeutic diagnosis for an increasing proportion of patients presenting with a renal mass. This need is particularly important for a small, incidentally discovered renal mass (less than 4 cm) as it can be a benign lesion in a significant percentage of cases. Recent studies have shown that needle biopsy is an accurate and safe method allowing for a precise histopathological diagnosis of the mass in most cases. The aims of the biopsy are (1) to assess the benign or malignant nature of the lesion, (2) to assess the primary or secondary nature of the lesion, and (3), in case of a primary malignancy, to determine histological prognostic factors, such as the tumor type. This review, based on the most recent literature and our own experience, is intended to provide a practical approach to the diagnosis, relying on appropriate morphologic assessment and the use of immunohistochemistry.

Influence of operator experience on performance of ultrasound-guided percutaneous liver biopsy.

The purpose was to evaluate the influence of radiologist's experience on the diagnostic yield and complications of a percutaneous liver biopsy (PLB) method. Six hundred patients underwent an ultrasound-guided PLB by an inexperienced operator in 25.2% of cases (experience of less than 15 percutaneous liver biopsies performed alone--group I) or by an experienced operator (experience of more than 150 percutaneous liver biopsies--group II). The two groups were well-matched with respect to sex, age, percentage with viral hepatitis without histological cirrhosis, number of needle passes, history of liver biopsy and pain before the biopsy. A histological diagnosis was available in 97.3% of cases without any significant difference between the two groups ( P=0.25). However, group II samples were significantly longer and contained more portal tracts ( P=0.01). Pain was mild immediately and 6 h after the biopsy, without significant difference between both groups. Eight vasovagal reactions (five in group II) and one arteriobiliary fistula (in group II) occurred. With the method of PLB used for this study, operator's experience did not influence either the final histological diagnosis or the degree of pain suffered.