Formes cliniques de l’urticaire chronique chez l’adulte

Chronic urticaria (CU) is a common illness, its main problem being essentially therapeutic. This review will focus on one of the sources of this problem, namely, the variety of mechanisms involved in CU. This requires that one be aware of the atypical clinical forms of CU and of CU associated with vasculitis. This review will consider some of the difficulties in the classification of CU. The conclusions of the 2003 Consensus Conference will be discussed, noting the importance of not carrying out complementary investigations once a good clinical history has been obtained and a complete physical examination has been achieved, even when an etiological diagnosis has not been made.     

La mesure du monoxyde d’azote dans l’air expiré chez l’enfant

If it can be confirmed that variations in the level of nitric oxide (NO) in expired air tells us something about the different physiological processes in which this molecule is involved (bronchomotor, vasomotor, immunoregulation), then we will have available a non-invasive technique that would be useful in conditions as varied as asthma, sickle cell anemia, mucoviscidosis and pulmonary arterial hypertension. This technique can be used routinely to the analysis of the concentration of NO in a single expired breath. However, analysis of the concentration of NO in several expired breaths, which is possible from the age of 8–9 years, also makes it possible, using a method that is now standardized, to determine the bronchial production of NO and its alveolar concentration, thus providing a method for differentiating the respective contribution of these two compartments. Other techniques now being developed should soon allow us to calculate even more precisely events during normal ventilation, which will then allow us to make these measurements in babies, in young children, and in patients on artificial ventilation. The aim of this present paper is to discuss the theoretical basis and the techniques of these different approaches.     

L’hypo-albuminémie contribue-t-elle à l’aggravation de l’insuffisance cardiaque ?

BackgroundHypoalbuminemia has now emerged as a powerful prognosticator in heart failure regardless of age, clinical presentation, left ventricular ejection fraction and usual prognostic markers. Growing evidence is that this prognostic value persists after adjusting for causative factors for hypoalbuminemia such as malnutrition, inflammation and liver dysfunction.ObjectiveTo address the prognostic relevance of hypoalbuminemia in frail elderly patients with well-characterized cardiogenic pulmonary edema at high risk for adverse outcome, beyond causative factors for low serum albumin levels. Serum albumin was measured after clinical stabilization to avoid hypervolemia.ResultsIn all, 67 patients with a mean age of 86 years were included. Hospital mortality was 30%. Patients who died and who survived were similar in age, ejection fraction, BNP concentration, serum creatinine, serum hemoglobin, total bilirubin and prealbumin. Patients who died had lower serum albumin levels (P < 0.001), higher blood urea nitrogen (P = 0.03) and higher C-reactive protein (P = 0.02). In multivariate analysis, serum albumin was the sole independent predictor of hospital death (P < 0.01), after adjusting for malnutrition (prealbumin P = ns), inflammation (C-reactive protein P = ns) and liver dysfunction (total bilirubin P = ns).ConclusionSerum albumin is a powerful prognosticator in frail elderly patients with acute cardiogenic pulmonary edema even after adjusting for main causative factors. These results suggest that hypoalbuminemia may contribute to the worsening of heart failure given the physiological properties of serum albumin that includes antioxidant activity and plasma colloid osmotic pressure action. Further studies are critically needed to address the relevance of prevention and correction of hypoalbuminemia in heart failure.     

Asthme difficile de l’enfant

Difficult asthma in children is defined by persistence of exacerbations, frequent symptoms requiring rescue bronchodilator, or persistent airway obstruction in spite of treatment with an inhaled steroid (≥ 800 mcg/day beclomethasone or equivalent) and a long-acting ß2 agonist. Management involves identifying other conditions that may mimic asthma, conditions associated with non-adherence to treatment, and avoidable factors that worsen symptoms. The pathological basis of genuine difficult asthma remains unknown. Different patterns have been described, depending on the cells involved (eosinophils, neutrophils), the degree of airway remodeling or distal localization of the lesions. Difficult asthma requires specialized management including evaluation of airway inflammation. Investigation by bronchoalveolar lavage and bronchial mucosal biopsies may lead to a better understanding of the pathophysiology of this problem and to better treatment of the child with genuine difficult asthma.     

Diagnostic de l’embolie pulmonaire

The diagnosis of pulmonary embolism (PE) is nowadays based on the sequential use of several diagnostic tests rather than on a single test. These diagnostic strategies are safe and have been prospectively validated. The first step after identifying patients with suspicion of PE is to establish the pre-test clinical probability. Several scores are available in order to make a standardised and reproducible assessment of the clinical probability, and therefore represent precious diagnostic tools. Indeed, clinical probability guides further investigations. Indeed, in patients with a low or an intermediate clinical probability or an “unlikely” probability, PE can be safely ruled out by negative D-dimers in approximately one third of outpatients without additional imaging. In case of positive D-dimers and a high clinical probability or a “likely” clinical probability, CT pulmonary angiography is now the recommended imaging technique. However, lower limb venous compression ultrasound and ventilation/perfusion scans remain useful in patients with contra-indications to CT, mainly those with renal insufficiency. Finally, some novel diagnostic tests seem promising. For example, V/Q SPECT has arisen as a highly accurate test and a potential alternative to CTPA. However, prospective management outcome studies are still lacking and are warranted before its implementation in routine clinical practice.     

Apport de l’échographie abdominale au cours de l’infection par le virus de l’immunodéficience humaine de l’adulte à Bangui (République centrafricaine)

Purpose

Describe the most frequent abdominal lesions in the ultrasound examination during the infection with HIV.

Patients and method

A transverse prospective study over a period of 12 months included 104 patients infected by the HIV and who presenting abdominal lesions.

Results Profits

The mean age of the patients was 36.2 years with extremes from 15 to 70 years and a sex-ratio of 1.3 in favour of the women. The age bracket from 30 to 39 years was the most affected touched. The abdominal lesions were dominated by: the lesions hepatobiliary in 41.2% of the cases, the deep adenopathies in 24.4%, deep lymph nodes in 24.4%, ascites in 14.4% and homogeneous or multinodulaire enlarged spleen in 11% of the cases. The renal, pancreatic and intestinal hurts were rare. About 30% of the patients had a rate of CD4 lower than 50 elements/mm³ and a little more than half (51%) was under for HIV.

Conclusion

Abdominal injury during the infection by the HIV are multiple. Abdominal echography allows to make an exhaustive work-up of the main lesions; any time, the results of this examination must be confronted with the biology and the anatomopathology for a diagnosis of certainty with the aim of better treatment.     

Lymphangiome kystique de l’abdomen chez l’adulte. Une tumeur très polymorphe

Aim

Describe the clinical polymorphism and diagnostic and therapeutic difficulties related to abdominal cystic lymphangioma in the adult.

Material and methods

Six cases of abdominal cystic lymphangioma, treated between 2000 and 2008, were retrospectively analysed. Were included only those patients with post-operative histological confirmation of the diagnosis.

Results

Three men and three women were operated on, ranging in age from 32 to 56 years (mean age 43 years). Symptoms were: abdominal pain in five cases, abdominal mass in three cases, intestinal obstruction in one case, one case of ascites, inferior member oedema in one case and a chance discovery in one case. Tumours were mesenteric in two cases, retroperitoneal in two cases, once in the spleen and once in the right adrenal gland. The size of the tumours varied between 50 and 450 mm. Complete resection was performed in all cases, requiring segmental resection of the intestine in one case, one splenectomy and one right adrenalectomy. After an average follow-up of four years, one retroperitoneal recurrence was noted.

Conclusion

Abdominal cystic lymphangioma in the adult present a very difficult diagnostic challenge and the correct diagnosis often remains elusive until tissue is obtained. The treatment of choice is complete surgical resection, although it does not always prevent local recurrence.     

Pseudo-obstruction intestinale chronique de l’adulte

Chronic intestinal pseudo-obstruction is a rare disease stemming from numerous causes characterized by disturbances in gastrointestinal motility. Symptomatology is often misleading and topography is variable, thus putting the clinician in serious difficulty. Diagnosis is based on a body of arguments, ranging from the clinical examination to surgical biopsies in expert centers. Treatment is non-consensual and mostly symptomatic. It is based on the use of prokinetics and optimal nutritional support. In the most serious cases, surgery can be required. The etiological treatment should be that of the causal disease when it exists and when the etiology is identified. Results of such treatment are variable. Chronic intestinal pseudo-obstruction is a disease which remains poorly understood. Progress had been made in terms of diagnosis and treatment but it seems obvious that a better comprehension of physiopathological mechanisms is necessary in order to improve our practice.     

Bilan des mercredis de l’asthme

Therapeutic education is becoming essential in the management of asthmatic children. The objective of this type of education is to modify in a durable manner the knowledge and behaviour of parents so as to decrease the morbidity of the disease.Objectives. – To describe the population of patients whose parents attend the asthma school at Necker–Enfants-Malades Hospital and to evaluate the impact of this educational activity.Methods. – We included the 54 children whose parents attended the asthma school from September 27th to December 31st, 2000. Two educational sessions were offered. Socio-demographic and medical data were collected and markers of this educational activity were assessed by means of three questionnaires. The parents first answered questions immediately after the educational session. The second questionnaire was completed 3 to 6 months later.Results. – The mean age of the patients was 8 years and 3 months. The patients were of French origin, living in traditional family structures in the Île-de France region. All had symptomatic asthma, affecting their quality of life and requiring active treatment. During the immediate evaluation, the knowledge and behaviour of the parents were judged to be correct. Some parents changed attitudes or behaviour later, particularly with respect to the means of managing asthma episodes or their beliefs concerning possible secondary effects of the treatment or the origins of the childˈs asthma. The follow-up period was too short, and the sample too small to draw any firm conclusions on the impact of this educational action on morbidity.Conclusion. – The structured educational action is effective. It should be adapted to patients and reinforced later because its effects may be transient.     

Quand la peau suscite l’urgence

Some skin diseases require an emergency medical intervention. This is obviously the case with several rare but life-threatening diseases including angioedema, anaphylaxis, acute drug reactions with blisters, pustules, or internal involvement, such as ‘hypersensitivity syndrome’/DRESS, or Kaposi-Juliusberg syndrome. More frequently patients are seeking emergency advice for an acute skin condition often accompanied by fever that looks dramatic to them, their relatives and general practitioner. This is the case of acute urticaria and acute contact dermatitis, especially on the face. For each of the above diseases, excluding urticaria, we will discuss the clinical presentation, the main differential diagnoses, the laboratory examinations that may be useful in emergencies and the principles of management.