Embolie paradoxale : mythe ou réalité ?

Paradoxical embolism should be suspected in front of a clinical phenomenon of thromboembolism associated with an anatomical right-to-left shunt. Others potential cardiac sources of thromboembolism must be ruled out. Strokes constitute the most frequent clinical manifestations of paradoxical embolism. Right-to-left left shunts are in connection with intracardiac defects (atrial septal defect and patent foramen ovale) or pulmonary arteriovenous malformations. The probability that a discovered PFO is stroke-related can be evaluated by a score. Therapeutic approaches for secondary prevention of recurrent stroke include antithrombotic and/or percutaneous treatments. The choice strategy begins to be clearer with the recent results of randomized controlled studies.     

Notre ennemi : le caillot. Thrombose coronaire : stratégie et arsenal thérapeutique

Intra coronary thrombus is  frequently encountered during acute coronary syndromes revascularisation procedures. It can also be encountered during angioplasty procedures in a stable angina context, although at a much lesser frequency.In both situations, it harbors a risk of poor angiographic result and poor prognosis. Intracoronnary thrombus may cause coronary occlusion at the angioplasty site or distal embolic  flow obstruction. Per procedure thrombus prevention rests on an prior optimal anti thrombotic treatment and in some circumstances the choice to defer the revascularisation procedure in the complex high risk setting. Treating the initiated thrombus remains controversial concerning thrombectomy and GPIIBIIIa inhibitors which are still in use in common practice. No reflow phenomenon is a particularly complex setting during cornary angioplasties, partially but not solely related to a thrombotic complication. It's treatment remains unclear in the absence of related oriented studies.The current mechanical and pharmacological antithrombotic therapies must remain common practice and used appropriately as of the clinical and angiographic setting, until further scientific outbrakes.     

Allergies alimentaires précoces du nourrisson de 6 à 18 mois : étude de 69 cas

We report our findings on a group of 69 children without cow’s milk allergy who had one or several other food allergies between 6 and 18 months of age. Their initial symptoms were of moderate to severe intensity: 61 (88.5%) of them had had systemic symptoms, including angioedema (52%), generalized urticaria (36%), laryngeal edema (13%) and asthma (10%). In 11.5% of the patients, the first sign was severe acute eczema that did not respond to the usual treatment. The most important allergens, those identified with skin tests, serological assay for specific IgE antibody and labial or oral challenge tests, were egg (60.2%), peanut (50%), fish (10.3%) and cashew nut (5.8%). An atopic background was present in 90% of these infants. Of those allergic to eggs, 53% subsequently had no reaction to this food, whereas only one child allergic to peanuts and none of those allergic to cashew nuts or fish became symptom-free. Forty-three percent of the infants suffered from multiple food allergies, and asthma had developed in 33 (48%) of them. In conclusion, the early onset of food allergy and the presence of multiple sensitivities in this group of patients pointed to the seriousness and the unfavorable evolution of their allergic condition.     

Les anémies hémolytiques immunologiques médicamenteuses : étude rétrospective de 10 observations

PurposeDrug-induced immune haemolytic anemia occurs in one case per million and can be fatal. Our aim was to describe the main characteristics and the type of drug involved.MethodsCases were retrospectively identified using spontaneous notifications collected by our pharmacovigilance centre and the results of immuno-hematological investigations performed by the laboratory of French blood establishment of Lyon between 2000 and 2012. Inclusion criteria were: an immune (positive direct antiglobuline test), hemolytic, anemia (haemoglobin < 100 g/L), with at least a plausible causal relationship with drug exposure according to the French method of imputability or the presence of drug-dependent antibodies, and exclusion of other causes of hemolysis.ResultsTen cases (5 men and 5 women, median age 54.4 years) were identified. Causal drugs were ambroxol, beta-interferon, cefotetan, ceftriaxone, loratadine, oxacilline, oxaliplatine, piperacilline-tazobactam, pristinamycine, and quinine. The median time to onset of anemia after starting the culprit drug was 6 days (2 hours to 16 days). The median nadir of hemoglobin was 57.9 g/L (range: 34–78). The direct antiglobulin test was positive in 8 patients: IgG only (n = 4), IgG and complement (n = 3), and IgA (n = 1). Drug-induced immune haemolytic anemia was considered as definite in 5 cases with positive drug-induced antibodies, probable in 4 cases negative for the detection of drug-induced antibodies but with plausible or likely causal relationship with drug exposure, and probable with an autoimmune mechanism in 1 case.ConclusionThe diagnosis of DIIHA is often difficult because of the similarities with autoimmune haemolytic anemia and the inconstant sensitivity of immunologic tests that sometimes required repetitive assessment.     

Troponinémie faussement positive chez un patient présentant un pneumothorax : cas clinique

A 20-year-old patient is admitted to the emergency room for chest pain occurring in the context of recurrent left complete pneumothorax. Ultrasensitive troponinemia is elevated to 20 times normal. Myocardial distress is attributed to pneumothorax following the negativity of cardiological examinations (EKG, TTE, cardiac MRI). The pneumothorax is drained with a favorable evolution.This is the first reported case of pneumothorax associated with a significant elevation of troponin without ECG change, TakoTsubo syndrome, or myocardial inflammation. Several mechanisms are considered: rotation of the myocardium around its axis, increase in pulmonary vascular resistance with overload of right ventricular pressure, disturbance of coronary blood flow on significant mediastinal compression with decrease in systolo-diastolic myocardial perfusion.     

Pathogénie des vascularites associées aux ANCA en 2021 : mise au point

Anticytoplasmic neutrophil antibodies (ANCA)-associated vasculitis (AAV) are rare systemic immune-mediated diseases characterized by small vessel necrotizing vasculitis and/or respiratory tract inflammation. Over the last 2 decades, anti-MPO vasculitis mouse model has enlightened the role of ANCA, neutrophils, complement activation, T helper cells (Th1, Th17) and microbial agents. In humans, CD4T cells have been extensively studied, while the dramatic efficacy of rituximab demonstrated the key role of B cells. Many areas of uncertainty remain, such as the driving force of GPA extra-vascular granulomatous inflammation and the relapse risk of anti-PR3 AAV pathogenesis. Animal models eventually led to identify complement activation as a promising therapeutic target. New investigation tools, which permit in depth immune profiling of human blood and tissues, may open a new era for the studying of AAV pathogenesis.