Acta Clinica Belgica最新文献

We describe a case of a woman with uncomplicated Type 2 diabetes mellitus, presenting with severe burning pains and intense redness of the legs, for which only cooling could provide relief. Although the description was classic of erythromelalgia, the lack of familiarity of the disorder caused considerable doctor's delay as well as the erroneous advice to start pain killers and amitriptyline. However, empirical discontinuation of simvastatin made all symptoms disappear. Erthyromelalgia is a rare but debilitating disease which is diagnosed by exclusion only. It usually occurs as a secondary feature to (hematologic) malignant disorders, autoimmune diseases or, infections or, most notoriously, to pharmacological agents. One of the latter might be simvastatin, and possibly all HMG CoA Reductase inhibitors.

Objective: The purpose of this study was to evaluate the attitudes of Flemish physicians and medical/nursing trainees regarding shared decision-making (SDM) and to determine possible differences based on sex, age, rank, occupation and specialty. Methods: A cross-sectional study was conducted between June and September 2017 in which the Patient-Practitioner Orientation Scale (PPOS) was translated and administered. Higher scores on the six-point scale indicate a patient-centered respondent. Independent t-tests, One and Two-way ANOVA and multivariate regression analysis with the variables sex, age, occupation and specialty were performed. Results: 266 responses from 93 physicians, 147 medical and 26 nursing students were analyzed. Mean sharing scores were 4,24 ± 0,64; 4,30 ± 0,61; and 4,30 ± 0,67, respectively. In the regression model, female sex (p < 0,10) and employment (p < 0,05) in general practice or internal medicine is predictive for higher sharing among physicians. Bivariate analysis revealed significant differences between specialisms (p < 0,05): pediatricians (4,79 ± 0,69), psychiatrists (4,74 ± 0,47), obstetricians/gynecologists (4,40 ± 0,38) and general practitioners (4,31 ± 0,59) scored higher on the PPOS than surgeons (3,84 ± 0,58). Conclusion: Flemish providers and trainees are disease-centered. Physicians' attitudes vary depending on their specialism, presumably due to prolonged exposure to the specific clinical context. Additionally, academic-trained nurses share the belief that the physician should decide and the patient should rely on his knowledge rather than his own. There is an urgent need for health policy and educational institutions to facilitate an environment in which SDM is supported.

Ecthyma gangrenosum (EG) is a potentially lethal skin infection, most commonly due to Pseudomonas aeruginosa with bacteremic dissemination and affecting mostly immunocompromised patients. We present two cases of EG in two men in Belgium recently admitted to our hospital, caused by a suspected coinfection by group A Streptococcus and Staphylococcus aureus, with a cutaneous dissemination, in which multiple impetigo lesions were the portal of entry. The first patient had no risk factors nor immunodeficiency, but the second was a homeless man with drug and alcohol abuse and advanced HIV infection. Early management of the condition is crucial, with initial broad spectrum antibiotherapy, rapidly narrowed down to the germs identified and skin lesion debridement if necessary. Any immunocompromising condition must be ruled out in any patient suffering from EG.

Mycobacterium abscessus is an environmental organism that has been implicated in pulmonary and extrapulmonary infections. Cases of furunculosis have been described in patients who underwent footbaths in nail salons; however, no cases of severe soft tissue infections or osteomyelitis have been reported following manicures. Here, we present the case of a 50-year-old woman who developed a felon in right index finger one week after having a manicure. She underwent incision and drainage of affected area. Cultures from purulence grew Mycobacterium abscessus. Imaging revealed osteomyelitis of distal phalanx. She was successfully treated with a prolonged course of antibiotics that included imipenem, linezolid, tigecycline, and clarithromycin. We highlight the importance of recognizing this uncommon complication and advocate the use of combined antibiotic regimens for an adequate treatment of this infection.

Objectives: The content of substances sold and consumed as party drugs is often unknown. They may contain inactive, contaminated or unexpected ingredients, and the dosage of the active components may vary considerably. Obviously, these phenomena increase the chances of a wrong or delayed therapy. To illustrate this point, we report 3 cases of clozapine intoxication at a dance event where most likely clozapine tablets were sold as party drugs.Methods: The three cases were part of a prospective toxicology study at a nocturnal indoor dance event.Results: One patient had to be intubated after obstructive breathing with desaturation and bradycardia, while the 2 other patients presented with syncope and altered mental status. All patients recovered after 20 minutes to 8 hours. Systematic toxicological analysis of the blood samples revealed the presence of clozapine (73-244 ng/ml) and its metabolite norclozapine (9-59 ng/ml). A pill, found in a pocket of one patient, was identified as Leponex® 100 mg (clozapine). This neuroleptic drug is mainly prescribed for treatment-resistant schizophrenia. In clozapine-naive subjects, orthostatic hypotension, bradycardia and syncope have been reported with a single 25 mg oral dose. Serum clozapine concentrations of the 3 cases were below the defined therapeutic range (350-600ng/ml) and the clozapine:norclozapine ratios were suggestive for recent drug intake.Conclusion: Routine drug screening may be unable to detect the toxic agent(s) involved. Whenever unusual symptoms are observed in an intoxicated patient, blood and urine samples should be sent to a reference toxicology laboratory.

Chronic respiratory infection with Burkholderia cenocepacia (Bc) in patients with cystic fibrosis (CF) is associated with accelerated decline in lung function and increased mortality. It is therefore important to attempt to eradicate new isolates, especially in children. However, there are no standardized guidelines to eradicate Bc. We report a case of successful eradication of new isolates of Bc in a 2-year-old child with CF using a combination of IV, nebulized antibiotics and sinus surgery.

Necrotizing myositis is an extremely rare soft tissue infection, mainly caused by Group A Streptococci. Although its presentation is nonspecific and seems harmless, it quickly leads to death in almost all cases. Therefore, diagnosis and treatment of necrotizing myositis are considered as medical emergencies. The 27 years old patient we report benefited from early diagnosis and care. Necrotic tissues were surgically removed 24 hours after the appearance of the first clinical signs. Intravenous antibiotherapy as well as immunoglobulin therapy were also given on the first day. Starting from this clinical case, we present a brief explanation of the pathogenesis, the key clinical features and appropriate tools for diagnosis. Then, adequate antibiotherapy, role of immunoglobulin therapy and interest of hyperbaric oxygenotherapy will be discussed.

Objectives: Melanoma induces lymphangiogenesis by secreting lymphangiogenic growth factors. The aim of this study was to examine the role of tumour lymphangiogenesis in survival of patients with cutaneous melanoma. Methods: Immunostaining of one hundred melanoma specimens was done with lymphatic-specific antibody D2-40. The quantification of tumour lymphangiogenesis - lymphatic vessel density (LVD) and lymphatic vessel area (LVA) - was calculated by computer-assisted morphometric analysis. Results: High intratumoural LVD, high peritumoural LVD, male gender, greater tumour thickness and Clark level IV/V were significantly associated with shorter disease-free survival (p= 0.001, p= 0.004, p= 0.004, p= 0.000 and p= 0.008, respectively) and melanoma-specific survival (p= 0.002, p= 0.002, p= 0.001, p= 0.000 and p= 0.017, respectively), while the trunk melanoma site was significantly associated only with shorter disease-free survival (p= 0.033). No significant association of LVA with survival was found. At multivariate analysis, peritumoural LVD [hazard ratio (HR) = 2.143, 95% confidence interval (CI) 1.097-4.189, p= 0.026)] and melanoma thickness (HR = 1.276, 95%CI 1.106-1.473, p= 0.001) were independent predictors of disease-free survival, while intratumoural LVD (HR = 3.446, 95%CI 1.465-8.109, p= 0.005), peritumoural LVD (HR = 2.742, 95%CI 1.313-5.725, p= 0.007) and gender (HR = 2.880, 95%CI 1.304-6.362, p= 0.009) were independent predictors of melanoma-specific survival. Conclusion: Тhis study shows that LVD enables better prediction of survival than melanoma thickness and other clinical-pathological parameters. Intratumoural LVD is the most significant predictor of melanoma-specific survival, while only peritumoural LVD has a significant impact on both, a disease-free survival and a melanoma-specific survival.

Pneumocystis jirovecii pneumonia (PJP) can be a severe indicator disease of acquired immunodeficiency syndrome (AIDS). We present two cases of homosexual male patients who came to the emergency unit of a Belgian hospital because of shortness of breath. Both men had been sent back home, initially diagnosed with a benign viral infection. Because of worsening symptoms and gradually evolving hypoxemia, both patients came back and were admitted to the hospital with a diagnosis of (microbiology proven) Pneumocystis jirovecii pneumonia. HIV serology in both men was tested and was clearly positive, indicating a new diagnosis of HIV infection. In this article, we provide an overview of this possibly severe AIDS defining condition. First, we give an introduction of the history of HIV/AIDS and its occurrence in homosexual males in Europe. Secondly, we provide an overview of the diagnosis and treatment of Pneumocystis jirovecii pneumonia. Finally, since the first case reports of Pneumocystis jirovecii pneumonia at the beginning of the AIDS epidemic also included homosexual men, we emphasize the potential importance of a sexual anamnesis in young male patients with an initial complaint of dyspnea.