SUBJECTAnalyze characteristics of neuromeningeal tuberculosis in the northeastern suburbs of Paris.MATERIAL AND METHODRetrospective study of 19 observations between 1988 and 1999.RESULTSThirteen cases of meningitis, 3 cases of meningitis associated with a tuberculoma and 3 cases with isolated tuberculoma were described. Young subjects (average age 46.4), foreign born (73.7%) were preferentially affected. Three patients were infected by the human immunodeficiency virus. Weight-loss and weakness (84%), fever (79%), headache (63%) dominate the clinical manifestations. The diagnosis delay was 56.6 days, and the therapeutic time, 8.6 days. The search for acid fast bacilli was positive only in one case on direct examination of the cerebrospinal fluid, whereas the culture was positive in 68.7% of the cases. Cerebral imagery was abnormal in13 patients. Average duration of antituberculous treatment was 13,4 months (range: 9-24). Corticosteroids were associated in 12 patients. Thirteen patients were cured, 3 died and 3 were lost to follow up.CONCLUSIONThe characteristics of neuromeningeal tuberculosis are not modified, but the diagnosis delay of the neuromeningeal tuberculosis, which conditions the prognosis, remains significant. The optimal duration of the antituberculous treatment and the conditions of the steroid therapy have to be specified.

SETTING: Peritoneal tuberculosis did not disappear from France during the 1990s.OBJECTIVE: To determine the characteristics of peritoneal tuberculosis in the north-eastern suburbs of Paris.METHOD: A retrospective study of cases diagnosed with peritoneal tuberculosis between 1990 and 1998 in five suburban hospitals in the north-cast region of Paris.RESULTS: Twenty-seven cases of adult peritoneal tuberculosis were diagnosed. There were nine women and 18 men, with a mean age of 37.5 years, 88.9% of whom were foreign born. General and digestive symptoms-abdominal pain and/or ascites-were present in 96.3% of the cases. The mean delay in treatment was 30 days. Peritoneal involvement was isolated in 25.9% of cases, and associated with pulmonary tuberculosis in 40.7% or hepatic tuberculosis in 25.9%. Co-infection with HIV (human immunodeficiency virus) was present 14.8% of cases. Culture of ascites fluid, laparoscopy and/or laparotomy (n = 17), with directed biopsy, aided in the formal diagnosis of peritoneal tuberculosis in 59.2%. One relapse and one case of multiresistance were observed. The mean duration of treatment was 9 months (range 6-12 months). Three patients received treatment with corticosteroids, and 91.2% of the patients achieved cure without sequelae.

A 49-year-old diabetic patient with abdominal pain was found at ultrasonography and computed tomography to have a cystic mass in the head of the pancreas with dilatation of the main pancreatic duct. The head of the pancreas and the duodenum were removed surgically. Examination of the operative specimen showed chronic pancreatitis, dilatation of the main pancreatic duct, and impacted mucus in the secondary ducts with villous proliferation of the ductal epithelium, thus allowing a diagnosis of intraductal adenomatosis. There was no evidence of malignancy. The resection margin was involved, and consequently the remainder of the pancreas was removed six months after the initial surgical procedure. A review of the literature showed that intraductal adenomatosis tends to spread and carries a high risk of malignant transformation. Surgery is required because of the risk of pancreatic duct obstruction and pancreatic cancer. Intraductal papillary tumour of the pancreas shares many characteristic with other adenomatous proliferation of the gastrointestinal tract (colorectal villous adenoma, bile duct adenomatosis) including the presence of villous structures with increased mucus production, a tendency to spread massively, and a high risk of malignant transformation.

Background: Big cities were particularly affected by tuberculosis in the 1990s. Methods: We studied 141 cases of extrapulmonary tuberculosis in patients not infected by HIV in the northeastern suburbs of Paris. Results: A total of 84 men and 57 women were included in the study. Their average age at diagnosis was 42.2 years. Some 73.6% of the patients were foreign-born. A total of 182 sites were identified in 141 patients. There was an association with pulmonary tuberculosis in 38 cases. The sites were: lymph node (48.9%), pleural (25.5%), skeletal (22.7%), genitourinary (5.7%), and meninges (5%). Unfavorable social conditions were frequently observed. The average duration of treatment was 10 months. Twenty-four adverse drug effects were noted. Sixty-eight strains of Mycobacterium tuberculosis were isolated. Five cases of primary resistance to at least one antituberculous drug and only one case of multidrug resistance were observed. Some 95.7% of the 93 patients who were not lost to follow up were cured. Conclusion: Independently of HIV infection, extrapulmonary tuberculosis is still present, particularly in the suburbs of big cities, where social conditions are poor. The significant number of patients lost to follow-up demands that measures be adapted for the therapeutic management of these patients.

We report 59 cases of lymph node tuberculosis in adults not infected by the human immunodeficiency virus (HIV), observed over a period of 5 years in the North Eastern suburbs of Paris. There were 31 women and 28 men; 84.7% were aged under 44 years; 69.5% were not French, and 78% had exclusive lymph node tuberculosis. A superficial distribution was found in 52 cases and a deep pattern in 17 cases. Cervical and supraclavicular lymphadenopathies were the most common (64.4%). General symptoms were present in 63% of cases. The diagnosis was established by fine needle aspiration in 10 cases and by biopsy in 36 cases. Three cases of primary resistance to anti-tuberculosis therapy were described. Lymph node tuberculosis is still present in the Paris region, independently of HIV infection, probably due to poor social conditions.

SETTING: Department of Seine-Saint-Denis, France.OBJECTIVE: To compare the presentation and outcome of Mycobacterium kansasii infections according to human immunodeficiency virus (HIV) status.DESIGN: Retrospective analysis of all the medical charts of adults meeting the diagnostic criteria of the American Thoracic Society for M. kansasii infection between 1991 and 1995.RESULTS: Between 1991 and 1995, 35 cases (23 HIV- [6%] and 12 HIV+ [34%]) were found, giving an annual incidence of 0.5/100 000. The following particularities were common to both groups: 1) frequency and prominence of respiratory and general symptoms, 2) rarity of clinically apparent extra-thoracic involvement, 3) bacteriological confirmation mostly obtained with respiratory tract specimens, 4) favourable bacteriological outcome, and 5) low mortality attributable to the mycobacterial infection. The most striking differences concerned chest radiography: HIV- patients had apical cavitated and nodular lesions, while HIV+ patients exhibited a variety of other patterns, including alveolar infiltrates, miliary lesions and/or thoracic lymphadenopathy.CONCLUSION: Apart from pulmonary radiographic differences, presentation and short-term outcome of M. kansasii infections were similar in HIV+ and HIV- patients.

Compare the efficacy and the tolerance of two treatments associating two NRTI and one NNRTI (Nevirapine). in naive patients HIV infected, with a follow up of one year.Twenty patients, two homogeneous groups, AZT+3TC+Nevirapine versus D4T+DDI+Nevirapine 70% undetectable patients at W52, in each group, with Chiron test 500 copys/ml. The CD4 mean increment is more important in the group D4T+DDI+Nevirapine. The long term use of 2 NRTI+1 NNRTI in naive patients positive for the future.

In 36 HIV-infected patients (33 plasmas), a study of platelet aggregation in the presence of four agents (adenosine diphosphate, collagen, ristocetin, and arachidonic acid) found evidence of platelet dysfunction in 45% of cases, including defective aggregation and excretion, probable Ib/IX complex deficiency, and responses indicating exaggerated platelet activation. These significant alterations were not accompanied with bleeding. Clotting disorders were also found, including elevations in levels of fibrinogen (39%), D-dimers (74%), and Willebrand factor (72%); a decrease in protein S activity (50%); and presence of antiphospholipid antibodies (28%). The clotting disorders were associated with greater severity of the HIV infection. No thrombotic or embolic events were noted although many patients had high D-dimer levels, protein S deficiency, a lupus-type circulating anticoagulant (33%), or antiphospholipid antibodies, suggesting that these abnormalities may not translate into clinical symptoms in HIV-infected patients.

A 49-year-old diabetic patient with abdominal pain was found upon ultrasonography and computed tomography to have a cystic mass in the head of the pancreas with dilation of the main pancreatic duct. The head of the pancreas and duodenum were removed surgically. Examination of the operative specimen showed chronic pancreatitis, dilation of the main pancreatic duct, and impacted mucus in the secondary ducts with villous proliferation of the ductal epithelium, establishing the diagnosis of intraductal adenomatosis. There was no evidence of malignancy. The resection margin was involved, and consequently the remainder of the pancreas was removed six months after the initial surgical procedure. A review of the literature showed that intraductal adenomatosis tends to spread and carries a high risk of malignant transformation. Surgery is required because of the risk of pancreatic duct obstruction and pancreatic cancer. Intraductal adenomatosis of the pancreas shares many characteristics with other adenomatous proliferations of the gastrointestinal tract (colorectal villous adenoma, bile duct adenomatosis), including presence of villous structures with increased mucus production, a tendency to spread massively, and a high risk of malignant transformation.

Les auteurs rapportent une observation originale d'une patiente, porteuse du virus de l'immunodeficience humaine de type 1 (HIV 1) developpant une tumeur du cavum qui s'est revelee etre une infiltration lymphocytaire polyclonale benigne de phenotype CD8.