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Resume Introduction Au cours de la rectocolite hemorragique (RCH), la distinction entre les manifestations pulmonaires de la maladie et les pneumopathies medicamenteuses est difficile. Observation Un patient âge de 72 ans, traite pour une RCH par mesalazine depuis quatre mois, etait hospitalise pour une insuffisance respiratoire febrile subaigue. Le bilan biologique retrouvait un syndrome inflammatoire, une hypereosinophilie et une elevation des IgE totales. Les prelevements a visee infectieuse etaient steriles. Le liquide du lavage bronchoalveolaire temoignait d’une cellularite normale avec une lymphocytose et une polynucleose a eosinophiles et neutrophiles (macrocytes 35 %, lymphocytes 23 %, polynucleaires neutrophiles 28 %, polynucleaires eosinophiles 14 %). Une biopsie pulmonaire chirurgicale permettait de retenir le diagnostic de pneumopathie organisee (PO) avec pneumopathie a eosinophiles. L’evolution etait favorable apres l’arret de la mesalazine et l’instauration d’un traitement par prednisolone a 1 mg/kg par jour. Neuf mois plus tard, le controle de la maladie digestive necessitait la reintroduction d’un derive salicyle (lavement rectaux de 4-acide aminosalicylique [ASA]) pendant cinq mois sans recidive de la PO. Discussion La PO est une manifestation extra-intestinale rare de la RCH. Ici, une reintroduction de la mesalazine sous une forme differente n’a pas ete suivie de recidive, mais n’excluait pas une iatrogenie.

Four cases of Streptococcus pyogenes infection due to an emm-type 11 strain, including one with a fatal outcome, occurred within a seven-member family. All strains shared biotype 5, pyrogenic exotoxin genes speB and speC, and resistance to kanamycin, tetracycline, macrolides and lincosamides. The identity of SmaI pulsed-field gel electrophoresis patterns confirmed their clonal origin. This highlights the ability of S. pyogenes to spread rapidly among family members. This first report of a family outbreak due to emm11 S. pyogenes reinforces the importance of surveillance of close family contacts of individuals with invasive streptococcal disease, and provides further support for antibiotic prophylaxis among the elderly.

We report a case of severe leptospirosis complicated with a multiple organ failure syndrome. A 62-year-old patient presented a picture associating fever, asthenia and myalgias, particularly intense on the calves. The assessment showed acute renal failure, hyperbilirubinemia, severe rhabdomyolysis and thrombocytopenia. Although initial management associating amoxicilline and continuous veino-venous hemodiafiltration, evolution was unfavourable, with SDRA and increase of hyperbilirubinemia. Administration of a bolus of 500 mg of methylprednisolone, associated with intravenous immunoglobulin (0,4 g/kg per day during five days), led to a rapid clinical and biological improvement. Immunomodulation aspects during leptospirosis are discussed.

The distinction between extra-intestinal manifestations of ulcerative colitis (UC) and drug-induced pneumonia can often be difficult.We describe the case of a 72-year-old male who presented fever and sub-acute respiratory insufficiency, after 4 months of treatment with mesalazine for ulcerative colitis (UC). Initial tests found serum C-reactive protein, eosinophil count and total IgE to be elevated. Routine bacteriological, fungal and mycobacterial cultures were negative. Bronchoalveolar lavage fluid cellularity was normal with elevated lymphocyte, neutrophil, and eosinophil counts (35 % mononuclear cells, 23 % lymphocytes, 28 % neutrophils, 14 % eosinophils). The diagnosis of organizing pneumonia (OP) with eosinophilic pneumonia component was confirmed after examination of a lung biopsy specimen. Clinical improvement occurred after cessation of mesalazine and initiation of prednisolone (1mg/kg/day). Nine months later, a recurrence of gastrointestinal symptoms required a 5 months reintroduction of an amino salicylate by topical therapy (4- acide aminosalicylique [ASA enemas]). There was no resurgence of the pneumonia.Organizing pneumonia is a rare extra-intestinal manifestation of UC. There was no resurgence of OP after amino salicylate enemas rechallenge but mesalazine-induced pneumonia cannot be excluded.

Resume Cinq cent cinquante cinq souches de shigelles ont ete isolees (12,6 % des coprocultures) au Centre Hospitalier des Armees Bouffard de Djibouti, en 21 mois, a partir d'aout 91. L'incidence des shigelloses augmente au fil des ans et une recrudescence est observee apres les fortes pluies, portant surtout sur Shigella flexneri , qui represente, avec Shigella sonnei , 80 % des souches en cause. Du fait du biais de recrutement, 88 % des shigelloses de cette serie, sont survenues chez des Francais expatries, en bonne sante et de facon sporadique dans l'immense majorite des cas. Un syndrome dysenterique ou des leucocytes dans les selles orientent le diagnostic. Les traitements classiques par amoxicilline associee ou non a l'acide clavulanique ou par le sulfamethoxazole-trimethoprime se heurtent a des resistances dans plus de la moitie des cas. Les cephalosporines orales de 2e generation et les fluoroquinolones en traitement court sont actuellement les traitements de choix.

Eosinophilic esophagitis is an unrecognized and emerging entity. Its incidence increases with allergic disorders. A 29-year-old man presented with a 4-year history of intermittent and paroxysmal dysphagia. The triad including allergy, young age, and impaction of foreign bodies, combined with a chronic dysphagia is almost pathognomonic of eosinophilic esophagitis. Endoscopic esophageal features can be diverse, so systematic esophageal biopsies are required. Diagnosis is established with the demonstration of an eosinophilic infiltrate with a cell count exceeding 15 eosinophils per high power field (×400). First line therapy includes swallowed topical corticosteroids and removal of an allergic cause, when it could be identified.

We report a 27-year-old man who presented with a Lemierre's syndrome associated with two uncommon complications: a septic sternoclavicular joint arthritis and a cavitating pneumonia.

We report a 75-year-old woman with a severe and symptomatic valvular tricuspid dysfunction, revealing a carcinoid syndrome, confirmed by an octreotid scan and liver biopsy. Carcinoid heart disease is a common complication of carcinoid syndrome associated with poor prognosis. Despite new pharmacological treatment, valve replacement surgery is the only curative treatment. Early diagnosis and multidisciplinary management could improve prognosis and quality of life of these patients.

Remitting symmetrical seronegative synovitis with pitting edema (RS3PE) syndrome is a rare type of seronegative polyarthritis occurring in the elderly. It can be associated to various diseases. We report a case of RS3PE syndrome associated with myopericarditis, leading to the diagnosis of polyarteritis nodosa in a 71-year-old patient admitted to the hospital for a febrile acute polyarthritis with pitting edema of the hands associated with a marked inflammatory syndrome. On second day of hospitalization, a sustained chest pain led to the diagnosis of myopericarditis. Muscular biopsy showed necrotizing vasculitis, characteristic of polyarteritis nodosa. The coexistence of RS3PE and myopericarditis has never been described in the literature. Its association with polyarteritis nodosa is also very rare and only one case has been previously reported.

Osteoarticular pathology in leprosy is common and described at all stages, but rarely as the most evident clinical manifestation. We report a case of borderline lepromatous leprosy with initial and disabling hands edema. The swollen hands syndrome is probably due to chronic Mycobacterium leprae tenosynovitis.

We report a case of severe leptospirosis complicated with a multiple organ failure syndrome. A 62-year-old patient presented a picture associating fever, asthenia and myalgias, particularly intense on the calves. The assessment showed acute renal failure, hyperbilirubinemia, severe rhabdomyolysis and thrombocytopenia. Although initial management associating amoxicilline and continuous veino-venous hemodiafiltration, evolution was unfavourable, with SDRA and increase of hyperbilirubinemia. Administration of a bolus of 500 mg of methylprednisolone, associated with intravenous immunoglobulin (0,4 g/kg per day during five days), led to a rapid clinical and biological improvement. Immunomodulation aspects during leptospirosis are discussed.

Streptococcus agalactiae has been traditionally considered as associated with neonates and pregnant women. Invasive diseases due to Streptococcus agalactiae are increasing in non-pregnant adults, especially with medical underlying conditions such as diabetes mellitus or neoplasia. Among these invasive manifestations, vertebral osteomyelitis remain exceptional. We report the case of a 49 year old man, without any risk factor, suffering from a vertebral osteomyelitis due to Streptococcus agalactiae. Assessment of virulence factors showed that the strain belonged to the serotype III, sequence type ST-17. The patient recovered well after prolonged antibiotic therapy. Although exceptional and associated with a favourable outcome, this case highlights the potential implication of Group B Streptococcus in vertebral osteomyelitis and the way to manage it.

Central diabetes insipidus is most frequently reported to occur after a trauma from surgery or accident. However, between 30 and 50% of cases are considered idiopathic. It's a rare complication of myelodysplastic syndrome.A 61-year-old patient presented central diabetes insipidus revealing, 17 months before, chronic myelomonocytic leukemia. Cytogenetics studies revealed monosomy 7. Acute myeloid leukemia appears 3 months after training rapid patient's death.Blood examination is necessary before to conclude idiopathic central diabetes insipidus. The discovery of chronic myelomonocytic leukemia implicates a rapid managing before its possible acute myeloid leukemia transformation. Indeed, prognosis of central diabetes insipidus and acute myeloid leukemia associated, in presence of monosomy 7, is very poor.

Although the presence of antiphospholipid antibodies is not an uncommon fact during infection, their responsibility in serious manifestations can still be debated and questions the existence of an actual catastrophic antiphospholipid syndrome or multivisceral faintings, triggered by the infection only, since the presence of antiphospholipid antibodies is not pathogenous.A 68-year-old man presented during an Escherichia coli urinary tract infection a septic shock with renal and cardiac insufficiencies, hepatic cytolysis and cholestasis and disseminated intravascular coagulation. There was a significant titer of antiphospholipid antibodies IgG (50 UGPL/ml) with an antibêta2-glycoprotein-1 positivity. The patient quickly recovered with antibiotherapy and intravenous immunoglobulins.Diagnosing the pathogeny of multivisceral faintings is founded of the clinical manifestations published during the catastrophic antiphospholipid syndrome, the evolution and the persistence of post recovery antibodies and the comparison with the visceral bouts that the sepsis exclusively as revealed.

In France, except in the overseas departments and territories, pulmonary eosinophilia rarely has a parasitic cause except among subjects who have traveled to tropic areas.A 19-year-old man was hospitalized for incidentally discovered hypereosinophilia. The thoracic CT scan showed several hyperdense nodules that suggested bilateral interstitial alveolar lesions. Diagnosis was finally based on serologic results positive for toxocariasis. A 14-day course of albendazole led to regression of the eosinophilia and of the radiographic images.The frequency of toxocariasis or visceral larva migrans syndrome is probably underestimated. In adults, the symptoms can be atypical and possibly serious. Albendazole, for 14 days, is the reference treatment.

The association of bullous pemphigoid and acquired haemophilia is reported.A 74 year-old man developed a bullous pemphigoid after decreasing corticotherapy, ecchymosis and haematomas revealing a high level of acquired anti-VIII antibodies (110 Bethesda UB units; TCA 98 s). Immunosuppressive treatment (cyclosporine, prednisone, azathioprine and bolus of cyclophosphamide) did not stop the disease. Perfusion of recombinant factor VIIa, human immunoglobulins and prednisone-azathioprine association permitted clinical and biological remission.Acquired haemophilia is idiopathic half the time. It can appear in autoimmmune diseases. Mortality is high. Only 4 cases of association with bullous pemphigoid have been reported in the literature. At the haemorrhagic phase, porcine factor VIII or more recombinant activated factor VII with human immunoglobulins are necessary. Immunosuppressive treatment is used to decrease production of anti-factor VIII antibodies.

Background ACPA and Rheumatoid Factor (RF) are included in the new 2010 ACR/EULAR criteria for RA diagnosis, although their presence is not compulsory. Indeed, 15 to 40% of RA patients do not produce ACPA during the course of the disease. Objectives To study the evolution and differential diagnosis of ACPA-negative RA patients. Methods In a bicentric retrospective study, 112 ACPA-negative RA patients diagnosed before the new ACR/EULAR criteria were followed regularly. Only 48 patients fulfilled the 2010 ACR/EULAR criteria for RA [1] and were further analysed. Their average age was 59 years old (range: 21-90), and the male-to-female sex ratio was 1 to 3. Evolution of the initial diagnosis and the proportion of patients reclassified with alternative diagnoses were analysed. Results Half of the patients (N=24) evolved to a different diagnosis than RA within 2.25 years [IQ25-75: 0,27-10]. New diagnoses were established from clinical signs, biological characteristics and patient history. Five had spondyloarthritis [2] including 3 psoriatic arthritis (fulfilling the Caspar criteria [3]), 5 had infectious diseases (1 Whipple disease, 1 Lyme borreliosis, 1 infective endocarditis, 1 helminthiasis and 1 parvovirus infection), 3 had polyarticular chondrocalcinosis, 1 had Sharp9s syndrome, 1 had hyperthyroidism, 1 had Sjogren9s syndrome, 1 had anti-synthetase syndrome, 1 had atrophic chronic polychondritis, 1 had Remitting seronegative symmetrical synovitis with pitting edema (RS3Pe), 1 had adult-onset Still9s disease, 1 had granulomatosis with polyangiitis, 1 had Mediterranean fever, 1 had sarcoidosis and 1 had lymphoma. Six were RF positive (25%). Sixteen had received a treatment, combined or not, with: steroids (N=13), DMARDs (N=14), or biologics (N=10). Additionally 10 of the 16 treated patients (62%) were non- or bad responders. The other half (N=24) had confirmed RA. Among them, 11 initially ACPA-negative became positive. ACPA positivity could be delayed up to five years after the first clinical signs. For the 13 remaining ACPA-negative patients, no new clinical event could lead towards an alternative diagnosis. Median follow-up was 9 years [IQ25-75: 7-14]; RF was positive for 17 (78%) patients; the majority had received a treatment, combined or not, with: steroids (N=14), DMARDs (N=19), or biologics (N=16). Forty percent were non- or bad responders. Conclusions ACPA-negative polyarthritis patients, even those fulfilling ACR/EULAR 2010 criteria, should be followed up for several years to see whether their diagnosis evolves. Among differential diagnoses, spondyloathropathies are the most common, especially psoriatic arthritis. Rare and atypical diseases must be considered when evolution seems non classical, all the more so in cases of non-response to DMARDs or biologics. Rheumatologists must be extremely vigilant to extra-articular manifestations, particularly cutaneous involvement and patient history. RF positivity remains a solid argument in favor of RA diagnosis and the ACPA status should be regularly checked. References Aletaha D, et al. Arthritis Rheum 2010;62:2569–81 Rudwaleit M, et al. Ann Rheum Dis 2011;70:25–31. Pedersen OB, Junker P. Ann Rheum Dis 2008;67:1495–6. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3673

We report a case of fulminant presentation of thrombotic microangiopathy associated with Hodgkin’s lymphoma in an HIV-infected patient. After aggressive therapy with antiretroviral drugs, chemotherapy, and plasmatherapy, complete remission of thrombotic microangiopathy and Hodgkin’s lymphoma was observed.

Miliary tuberculosis is rare and requires rapid diagnosis. Outcome is fatal in 25% of the cases. Since radiography and laboratory tests contribute little to early diagnosis, clinical findings are primordial. Antituberculosis antibiotic therapy is frequently started before microbiological confirmation of the diagnosis.

Management of blood eosinophilia in travelers returning from the tropics is controversial. In this prospective study, 102 asymptomatic tropical travelers underwent investigation and treatment for hypereosinophilia. In contrast with direct tests for parasitic infection which were positive in only 15% of cases, immunological tests were suggestive of helminthic infection is 77%. The most common diagnoses were toxocarosis (49%), strongyloidiasis (30%), and filariasis (19%). Anti-parasite treatment was undertaken based on laboratory findings (12 cases) or on presumptive diagnosis using two-agent therapy (ivermectin and praziquantel) in 13 cases or three-agent therapy (ivermectin, praziquantel, flubendazole) in 77 cases. As a result of treatment, eosinophil count returned to normal in 61% of cases and decreased in 30%. These findings suggest that presumptive treatment of blood eosinophilia can be undertaken in tropical travelers using three anti-parasitic drugs: ivermectin (1 x 0.4 mg/kg), flubendazole (2 x 100 mg per day for 3 days), and praziquantel (1 x 40 mg). As a precaution before using ivermectin, tests should be performed to detect loiasis which can lead to adverse reactions.

Extrapulmonary manifestations of Legionella pneumophilia infection are infrequent. Cardiac involvement can occur. We observed an unusual case which led to acute pericarditis and reviewed the literature on cardiac involvement, particularly pericarditis, in patients which legionellosis.