Hématomes surrénaliens non traumatiques : série rétrospective de 20 cas

IntroductionSpontaneous adrenal hemorrhages (AH) are a rare condition with no consensus about their management.MethodsPatients were identified using the Medicalization of the Information System Program database, imaging software and a call for observations to internists, intensivists and obsetricians working at our institution. Adult patients whose medical records were complete and whose diagnosis was confirmed by medical imaging were included.ResultsFrom 2000 to 2007, 20 patients were identified, including 15 were women. The clinical onset of AH was non-specific. In five cases, AH occurred during pregnancy; four of them were unilateral and right sided. The etiology of the other fifteen (bilateral adrenal hemorrhage in 11) were as follows: antiphospholipid syndrome (n = 8), heparin-induced thrombocytopenia (n = 4), essential thrombocythemia (n = 3), spontaneous AH due to oral anticoagulants (n = 1), complication of a surgical act (n = 3), and sepsis (n = 3). In seven cases, two causes were concomitant. The diagnosis of AH was often confirmed by abdominal CT. An anticoagulant treatment was initiated in 16 cases. Ten of the eleven patients presenting with bilateral adrenal hematomas were treated using a long-term substitute opotherapy. One patient died because of a catastrophic antiphospholipid syndrome.ConclusionThe clinical onset of HS is heterogeneous and non-specific. The confirmatory diagnosis is often based on abdominal CT. The search for an underlying acquired thrombophilia is essential and we found in this study etiological data comparable to the main series in the literature. Adrenal insufficiency is most of the time definitive in cases of bilateral involvement.     

Les kystes hydatiques cardiaques à propos de 17 cas opérés

Cardiac hydatid cyst is a rare parasitic disease. The purpose of this study was to describe the clinical, pathological features and the outcome of the surgical treatment of cardiac hydatid disease in our unit over a twenty-year period.MethodsBetween May 1994 and May 2014, seventeen cases of cardiac hydatid cysts were operated at our unit. Overall, twelve patients were male (mean age 25 ± 13 years). All patients were complaining of dyspnea and 71% presented with chest pain. The diagnosis, based on histological examination, was suspected on echocardiography and computed tomography of chest.ResultsOur study revealed five possible locations, which were in decreasing order of frequency: left ventricle, interventricular septum, right ventricle, left atrium and pulmonary artery. The surgical procedure was a controlled puncture and aspiration of the cyst content, with cystectomy (69%), or pericystectomy (31%). The resulting cavity left open in 6 cases (37.5%) or carefully closed in 10 (62.5%). Hospital mortality was 11.8% (n = 2). Morbidity was marked by conduction abnormalities (n = 2), bleeding and hematoma of the residual cavity that required surgical treatment (n = 3). Eleven patients were followed with a mean period of 40.5 ± 19.4 months. At follow-up, neither late deaths nor recurrence have occurred.ConclusionCardiac hydatid cyst is a serious disease whose treatment is surgical. Cystectomy and pericystectomy remain the two surgical techniques able to offer good chance of cure with acceptable morbidity and mortality.     

Facteurs prédictifs de la récidive postopératoire après résection iléocæcale pour maladie de Crohn

Introduction

Although the proven efficacy of many biologic agents in inducing and maintaining remission in Crohn’s disease, near 80% of patients require intestinal resection during their lifetime. This surgery is not definitively curative. In fact, postoperative disease recurrence is common and is considered as a one of the major problems encountered when managing Crohn’s disease. Aims: to assess the risk factors for postoperative recurrence after ileocecal resection for Crohn’s disease.

Patients and methods

The study included all Crohn’s disease patients who underwent ileocecal resection between 2000 and 2009. Disease recurrence was defined as endoscopic evidence of disease activity with or without symptoms. To determine the risk factors for postoperative recurrence of Crohn’s disease; we performed univariate analysis of the different variables proposed in the literature for their influence on the postsurgical outcome followed by multivariate analysis by logistic regression.

Results

Fifty two patients were included. Fifteen patients (28.8%) patients developed disease recurrence within a mean follow up of 31.9 months [1–126]. In univariate analysis, familial history of chronic inflammatory intestinal disease (P = 0.007), ileocecal resection occurring during the first year after the diagnostic of Crohn’s disease (P = 0.004), length of the resected small bowel (P = 0.025) and presence of granulomas(P = 0.035)were associated with a high risk of postoperative recurrence. In multivariate analysis, surgery during the first year after the diagnostic of Crohn’s disease was the only independent variable correlated to postoperative recurrence.

Conclusion

After an ileocecal resection for Crohn’s disease, the recurrence is relatively common particularly in patients who underwent their surgery during the first year after the diagnostic of CD.     

Gestion des toxicités induites par les inhibiteurs de checkpoint immunologique : données de la réunion de concertation pluridisciplinaire « ToxImmun » en Occitanie Est

Immune checkpoint inhibitors (ICIs) can cause numerous and complex immune-related adverse events whose management need a multidisciplinary approach. Herein, we investigated 114 requests, mostly concerning patients suffering from lung cancer, that were submitted to the « ToxImmun » multidisciplinary meeting in Eastern Occitania between December the 17th 2018 and January the 20th 2020. The leading reasons for the request concerned the putative causal link between immunotherapy and immune-toxicity and its management, followed by possible retreatment after temporary withdrawn because of adverse event, and finally the possibility to initiate ICIs in patients with pre-existing autoimmunity. Colitis, hepatitis and myocarditis were the most frequent immune-related adverse events (IRAEs), both all grade and grade 3–4. Sicca syndrome (with or without Sjogren criteria) was also frequent (26% of cases) and seems to be associated with severe toxicity and multi-toxicity. The mean time to first IRAE was 3.8 months, a time shortened with the use of anti-PD-L1 agents or ICI combination. A majority of requests came from initial evaluation by the internist confirming the early and main role of this specialty in the management of immunotoxicity. Expansion of this regional multidisciplinary meeting, coordinated by internists and medical oncologists, could improve management of immune-related adverse events for the patients’ benefits.     

Histamine,récepteurs de l’histamine et anti-histaminiques : données récentes

Histamine was discovered at the beginning of the 20th century. It has been recently shown that immunocompetent cells (T lymphocyte, dendritic cell) are capable of histamine synthesis and that histamine can regulate the Th1/Th2 balance. This immune regulation by histamine is related to its activity as a potent polarizing factor for dendritic cells, giving rise to DC2 dendritic cells that are involved in the differentiation of T helper cells towards Th2 phenotype. The majority of histamine is metabolized by N-methyltransferase. A common polymorphism of this enzyme that is associated with decreased enzyme activity has been associated with asthma. Histamine binds to four receptor types that are expressed on different types of cells and that mediate the numerous actions of histamine. H₁-receptors exhibit constitutive activity that is inhibited by several H₁-receptor antagonists, which therefore display a negative intrinsic activity called inverse agonist activity. In addition, the cerebral P-glycoprotein-mediated efflux of recent H₁-receptor antagonists may explain the lack of nervous system side effects of second-generation anti-histamines.     

Nouveautés en allergologie : eczéma de contact

With respect to contact allergy, the latest observations relate to the allergens and the test methods. Every year there are a few reports of cases of contact allergy to new products and to others that are little known. The most interesting are the allergens that cause the minor epidemics that are reported by cosmetic vigilance committees, for example, cases caused by depilatory waxes, hairdressing products and perfume components. With respect to the test methods, the standard series continues to evolve. Francophone physicians are in the process of bringing up to date a battery that includes allergens that they are likely to encounter and that they believe should be included sooner or later in the european standard series. Finally, it would be interesting to test irritant products to define more precisely patients’ reactivity threshold so that we could identify those who are hyperreactive and candidates for false positive reactions.     

Actualités dans la physiopathologie de la sclérodermie systémique : vers de nouvelles opportunités thérapeutiques

Systemic sclerosis is a rare connective tissue disease characterized by skin and several internal organ fibrosis, systemic vasculopathy and immune abnormalities. Even if fibroblasts and endothelial cells dysfunction, as well as lymphocytes and other immune cells implication are now well described, the exact origin and chronology of the disease pathogenesis remain unclear. Oxidative stress, influenced by genetic and environmental factors, seems to play a key role. Indeed, it seems to be implicated in the early phases of fibrosis development, vasculopathy and in immune tolerance abnormalities shared by all patients, although disease expression is heterogeneous. To date, no curative treatment is available. Even if immunosuppressive treatment or drugs acting on vascular system are proposed for some patients, overall, treatment efficiency remains modest. Only autologous hematopoietic stem cells transplantation, reserved for patients with severe or rapidly progressive fibrosis, has recently demonstrated efficiency, with lasting regression of fibrosis. Nevertheless, this treatment can expose to important, life-threatening toxicity. In the last decade, new mechanisms implicated in the pathogenesis of systemic sclerosis have been unraveled, bringing new therapeutic opportunities. In this review, we offer to focus on recent insights in the knowledge of systemic sclerosis pathogenesis and its implication in current and future medical care.