The Use of Placebo as a Provocative Test in the Diagnosis of Psychogenic Non Epileptic Seizures

Psychogenic non epileptic seizures (PNES) are clinical events of psychological nature. Video-electroencephalography monitoring (V-EEGM) is a valuable method for the diagnosis of PNES and may be combined with provocative tests to induce seizures. The use of placebo in provocative tests for the diagnosis of PNES is controversial because of associated deception, and contrasts with the use of truly decreasing epileptogenic threshold techniques such as hyperventilation and photo stimulation. We present a clinical case of a pregnant woman with a past history of refractory epilepsy, admitted in the obstetric department due to unremitting seizures. In this clinical context, non-deceiving provocative tests such as hyperventilation and photo stimulation could be potentially harmful, nevertheless, the use of intravenous saline injection presented as a safer alternative to diagnose PNES and hence obviate an urgent caesarean. This case illustrates a disproportionate risk of causing harm when telling the truth, in comparison with the benefit of avoiding such risk, although deceiving the patient. This is a clinical example of how considerations concerning the use of placebo must be evaluated in an individual basis.     

Primary digestive tract Kaposi sarcoma with idiopathic CD4+ lymphocytopenia, HIV negative, HHV8 positive]

A 52-year-old Tunisian patient had fever, impaired health and several opportunistic infections (Campylobacter jejuni, Mycobacterium hominis, Herpes virus, Giardia intestinalis, Vibrio metschnikovii). Lymphocytopenia was noted (348/mm3; CD4+: 2.2%; CD4+/CD8+: 0.1). Polymerase chain rection search for HIV was negative in serum and in tumor tissue. Diagnosis of primary digestive Kaposi sarcoma was established at autopsy due to the deep location of the lesions. There was an ulcerofungating tumor spreading over 1.3 m of the duodenojejunum. This is the fourth reported case of CD4+ lymphocytopenia, a new and very rare immunodeficiency syndrome recently defined by the Centers for Disease Control. We detected human herpes virus 8 by immunohistochemistry of tumor tissue. Human herpes virus 8 is implicated in the pathogenesis of Kaposi sarcoma.     

Apropos of 45 cases of cutaneous tuberculosis in Tlemcen (western Algeria)

The cutaneous tuberculosis (CTB) is still frequent in Algeria. From March 81 through December 87, forty-five cases were observed in our service of Dermato-Venereology (CHU Tlemcen), something like 6.4 cases per year. The two sexes are equally represented; 66.6% aged under 40; 66.6% are living in cities and have modest social and economical conditions; 20% were inoculated with BCG; previous CTB (personal 8.8% of family 11.1%) were hardly seen. It took some 44% of the patients less than a year to ask for a diagnosis, after receiving several non specific treatments. The rest took longer to come for consultation and in one case, the disease evaluated for 28 years. One explanation is that sometimes the affection causes very little annoyance. The clinical aspects observed were often evocative: Lupus vulgaris, 28.8%, scrofuloderma, 28.8%, specific adenitis, 13.3%, tuberculosis verrucosa cutis, 13.3%, gum, 13.9%, ulcerous CTB, 2.2%. Tuberculin skin test was positive for 86% of the cases and was taken into consideration when it reaches over 15 mm (46%), and with discomfort (4.4%). The treatment was efficient in the large majority of the cases. However, 29.5% of the patients gave up before the end of the cure. We insist upon the priority of the relationship doctor-patient in the case of a chronicle affection, which is less uneasy for some and shameful for a great many.