Quel est l’intérêt de rechercher un hypogonadisme chez un patient présentant des ulcères de jambe récidivant depuis l’âge de 20 ans ?

Androgen replacement therapy has been reported to have a beneficial effect in patients with Klinefelter's syndrome or perforating plantar ulcers. We report the case of a 55-year-old man with a 35-year history of leg ulcers and venous insufficiency. His leg ulcers healed 4 months after a management scheme including vascular rehabilitation (intermittent pressure therapy, ankle mobilization, multiple layer compression bands on the lower limbs), skin grafts and foam sclerotherapy of the great saphenous vein. The ulcers recurred 1 month later. This recurrence and the unusually young age for development of venous leg ulcers led to a search for a rare cause. The diagnosis of anterior pituitary failure was established. Sclerotherapy and androgen replacement therapy led to complete healing without recurrence at the 1-year follow-up visit. A link between androgen deficiency and fibrinolysis, protein synthesis deficiency, inflammation and trophicity is well documented in the literature. A search for hypogonadism may be useful in young patients presenting a longstanding history of leg ulcers or in patients with suspected andropause irrespective of age.     

Quelles raisons pour un traitement probiotique chez les nourrissons allergiques ?

The underlying denominators in allergic disease may be outlined as genetic susceptibility, aberrant barrier functions of skin epithelium and the gastrointestinal and respiratory tracts, and dysregulation of the immune response to ubiquitous environmental antigens. The prevalence of atopic diseases has been progressively increasing in Western societies. Genetic factors are unlikely to explain the emergence of the atopic type of immune responsiveness to antigens such as those deriving from food, food allergy being frequently its first manifestation. Two candidate explanatory factors include altered hygiene and nutrition. The hygiene hypothesis conceives the rapid increase in atopy to be related to reduced exposure to microbes at an early age. The earliest and most massive source of microbial exposure is associated with the establishment of the gut microflora. Diet can also have a major effect on the composition and activity of the gut microflora. In infants, it is thought that those who are breast-fed have a natural predominance of bifidobacteria while the formula-fed have a profile which is more complex and similar to the adult microflora. Since the gut microflora directs the regulation of systemic and local immune responsiveness, including hyporesponsiveness to antigens derived from microorganisms and food, modulation of the gut microflora has been taken as a treatment target in allergic disease. Indeed, differences in the neonatal gut microflora were shown to precede the development of atopy, suggesting a crucial role of the balance of indigenous intestinal bacteria for the maturation of human immunity to a nonatopic mode. Probiotics are live microbial food supplements or components of bacteria, which have been demonstrated to have beneficial effects on human health. Probiotics may create optimal conditions to redirect the allergic immune responsiveness to a healthy balance, and to control local and systemic allergic inflammation before altered structure and function in the target organ develops.     

Faut-il modifier la prise en charge du syndrome de Klinefelter pour améliorer les chances de paternité ?

Until a few years ago, Klinefelter syndrome with a homogeneous 47.XXY karyotype was considered a model of absolute male sterility. In this review, we will discuss: (1) potential fertility following TEsticular Sperm Extraction-IntraCytoplasmic Sperm Injection (TESE-ICSI), (2) the physiopathology of spermatogenic failure and the origin of focal spermatogenesis and risk of aneuploidy in potential offspring, (3) the advantage of searching for and cryopreserving spermatozoa in adolescent instead of adult patients. In previous published series, TESE was successful in almost 50% of patients and pregnancy rate following ICSI was not obviously different from other causes of spermatogenic failure. The rate of positive sperm extraction seemed to be better for younger patients. During childhood, the survival rate of 47.XXY spermatogonia is low. However, a few spermatogonia are able to eliminate their extra X chromosome, giving rise to rare clones of 46.XY gonia which are the origin of rare foci of complete spermatogenesis after puberty. Several arguments suggest that this focal spermatogenesis decreases with age. This suggests there would be a benefit to patients if TESE were performed in adolescences and spermatozoa were cryopreserved. In addition, androgenotherapy is a common treatment of Klinfelter syndrome but carries a risk of decreasing focal spermatogenesis by lowering gonadotropins. Preservation of spermatozoa from adolescence by TESE would allow androgenotherapy to be prescribed with less concern for future reproductive capacity. Controlled studies should be done to determine the best age for TESE-ICSI in 47.XXY homogeneous Klinefelter syndrome patients.