L’entérite : une manifestation peu fréquente et corticosensible du lupus érythémateux systémique

Introduction

. Lupus enteritis is a rare manifestation of systemic lupus erythematosus. The clinical manifestations are variable including abdominal pain, diarrhea, nausea and vomiting. Lupus enteritis is thought to be related to vasculitis.

Case reports

. We report here three new cases. All three patients aged of 45, 24 and 43 years (two females and one male) were admitted for abdominal pain, vomiting and diarrhea, and fulfilled the ACR criteria of systemic lupus erythematosus. The diagnosis of lupus enteritis was retained on the CT scan findings and the favorable outcome on corticosteroids after infectious etiologies were excluded.

Conclusion

. Lupus enteritis is thought to be one of the most common causes of acute abdominal pain in systemic lupus erythematosus. The diagnosis is based on clinical, radiological and biological findings. A good response to corticosteroids is usually reported.     

Utilidad de la tomografía por emisión de positrones en la detección de metástasis ocultas extratorácicas en el carcinoma broncogénico no células pequeñas

Introduction

Positron emission tomography combined with computed axial tomography (PET/CT) is used for staging non small cell lung cancer (NSCLC). This study aims to describe PET/CT findings of unsuspected extrathoracic metastasis when used in mediastinal evaluation of patients with apparently resectable NSCLC.

Patients and method

Prospective and concurrent study including all NSCLC patients between June 2004 and November 2006 who underwent PET/CT after considering them as candidates for surgery, with resectable disease after bronchoscopy, thorax and abdominal CT, brain CT and bone gammagraphy evaluation, if metastasis at these locations were suspected. Metastasis were confirmed histopathologically or assumed when they had a compatible evolution.

Results

A total of 91 patients with NSCLC underwent PET/CT. In 24 of them (26%) at least one suspicious extrathoracic uptake was seen. In 7 patients (7.7%) those uptakes were NSCLC extrathoracic metastasis hidden from conventional staging. In 3 of these cases (13.1%) extrathoracic uptakes corresponded to metacrhonous tumours or pre-malignant conditions. Benign lesions were found in 12 patients (13.1%), and in 2 cases (2.2%) the uptake origins were undetermined.

Conclusions

PET/CT is a complementary diagnosis method for assessing hidden metastases which could modify the therapeutical approach in patients otherwise suitable for surgery.     

Hémorragie surrénalienne bilatérale révélant une hyperhomocystéinémie

Introduction

Bilateral adrenal hemorrhage remains a rare disease. It has several etiologies, and clinical presentation is not specific.

Case report

We report a 45-year old man without known prothrombotic factor who presented with acute left sided abdominal pain left revealing a bilateral adrenal hemorrhage. The diagnostic work-up identified a significant hyperhomocysteinemia associated with a previously undiagnosed homozygous mutation of the 5,10 methylene–tetrahydrofolate reductase gene. The outcome was associated with the occurrence of an adrenal insufficiency.     

Polyradiculonévrite aiguë révélant un lupus érythémateux systémique : une présentation inhabituelle d’évolution fatale

Introduction

Neurological manifestations of systemic lupus erythematosus are common and numerous. They mainly involve the central nervous system, peripheral involvement being rare. Acute polyradiculoneuropathy is very uncommon.

Case report

We report a 44-year-old man, who presented with acute polyradiculoneuropathy revealing systemic lupus erythematosus. Outcome was fatal despite treatment with corticosteroids and immunoglobulin.

Conclusion

Acute polyradiculoneuropathy is a very rare manifestation of systemic lupus erythematosus and can compromise functional and life prognosis. Early diagnosis and management are crucial.     

Hallazgos radiológicos en pacientes con esquistosomiasis importada

Introduction

Imaging techniques, primarily ultrasound, are useful in the diagnosis and monitoring of patients with schistosomiasis in endemic areas.

Methods

Study of 219 patients treated in sub-Saharan Tropical Medicine Unit with a diagnosis of imported schistosomiasis by imaging techniques investigations including plain abdominal radiography and ultrasound.

Results

A total of 17.8% of patients who had an abdominal X-ray showed findings suggestive of schistosomiasis, in most cases bladder calcifications. In 73 patients (41%) ultrasound showed pathological findings, mainly diffuse or focal wall thickening (26 patients), nodular lesions (n = 14), and pseudopolyps (n = 8). One patient, who had a large bladder mass (9 cm) and bilateral ureterohydronephrosis, was finally diagnosed with squamous cell carcinoma of the bladder. Ultrasound liver abnormalities were found in 10 patients, 4 with signs of portal hypertension, of which 3 had the characteristic periportal fibrosis in schistosomiasis.

Conclusion

Imaging studies, especially abdominal and bladder ultrasound, are useful for diagnosis, the study of disease and monitoring of patients with schistosomiasis in non-endemic countries.     

Epiploic appendagitis: report of a case

Primary epiploic appendagitis are considered to be a rare cause of acute abdomen. They are frequently misdiagnosed as either acute appendicitis or acute diverticulitis and the diagnosis is usually made during surgery. We report a case in which computed tomography (CT) suggested the diagnosis and helped in avoiding unnecessary surgery.     

Sarcoïdose musculaire : à propos d’un cas avec atteinte des muscles et des fascias et revue de la littérature

Introduction

Muscular involvement in sarcoidosis is noted in 50 to 80% of the patients when systematic muscle biopsies are carried out. Nevertheless, symptomatic forms are rare and three different types can be distinguished: nodular, chronic myopathy and acute myositis.

Case report

We report a 43-year-old man who presented with sarcoidosis involving in muscles, fascia and articulations. The diagnosis of sarcoidosis was supported by magnetic resonance imaging and positron emission tomography imaging and confirmed by a muscle biopsy. Clinical manifestations resolved with corticosteroids and methotrexate.

Conclusion

We review 23 cases of sarcoidosis myosistis most similar to ours. The commonest presentation is the involvement of the proximal limb muscles in association with elevated serum muscle enzymes.     

Primary epiploic appendagitis: Reconciling CT and clinical challenges

Objectives

Our aim was to explain the spectrum of clinical and CT findings in 18 patients with acute epiploic appendagitis.

Methods and Materials

We reviewed the clinical records and CT pictures of 18 consecutive patients seen in Nejran Armed Forces Hospital, Nejran, Kingdom of Saudi Arabia and Sohag University Hospital, Sohag, Egypt between July 2006 and June 2013 with a diagnosis of primary epiploic appendagitis.

Results

The age ranged between 22 and 64 years old with a mean of 44.3. Males were affected in 72 % of cases. Eleven patients had acute pain in left lower quadrant. Nausea and vomiting were encountered in four patients. No fever was recorded in all cases. Leukocytosis was found in four patients and C-reactive protein (CRP) was high in five. CT scan diagnosed primary epiploic appendagitis (PEA) in 15 patients, while 3 patients were diagnosed intraoperatively. The left colon was affected in 11 patients. All patients except one had a central fatty core surrounded by inflammation with size ranging between 1.5 and 3.5 cm in length. Fifteen patients were treated conservatively, and three cases underwent surgical exploration. Ten patients (55.5 %) completed the follow up schedule. Complete resolution was noted in three patients at 2 weeks, in six patients at 3 months, and only one patient had residual changes at 6 months.

Conclusion

PEA is a challenging clinical diagnosis, and CT scan is extremely necessary in diagnosing this disease accurately. The awareness of the surgeons concerning this rare occasion will avoid unnecessary hospital admission and operative treatment.

     

Intoxication par ingestion de plombs de pêche

Introduction

Lead colic is a rare cause of abdominal pain. The diagnosis of lead poisoning is most often mentioned in at risk populations (children, psychotic patients).

Case report

We report a 21-year-old man who presented with colicky abdominal pain. Abdominal plain radiograph showed multiple intracolonic metallic bodies. Markedly elevated lead and zinc protoporphyrin serum levels confirmed the diagnosis of lead poisoning. The patient reported that he commonly chewed fishing lead sinker and may sometimes swallow them during the preparation of fishing rod. Clinical outcome was favourable with chelation therapy.

Conclusion

Lead poisoning following fishing sinker ingestion is very uncommon. Diagnosis may be discussed in the presence of foreign metallic bodies on plain abdominal radiograph and confirmed by high serum level of lead. A prompt treatment with chelation therapy and digestive emptying is usually effective.     

La pancréatite lupique : une série de six cas

Purpose

The occurrence of acute pancreatitis in systemic lupus erythematosus (SLE) is known but rare, and is exceptionally the presenting manifestation. Its pathogenesis is multifactorial, and it is difficult to separate what belongs to vasculitis, thrombotic phenomena in the context of an associated antiphospholipid syndrome, or iatrogenic complications. We report on six cases of lupus pancreatitis.

Methods

This is a retrospective monocenter study of 110 patients with SLE. The diagnosis of lupus pancreatitis was established after exclusion of other causes of pancreatitis.

Results

Five women and one man (5.4%) with a mean age of 36.3 years presented with lupus pancreatitis. In four patients the pancreatitis was concurrent with the diagnosis of SLE and it occurred later during an exacerbation of the disease in the two remaining patients. In all patients, pancreatic manifestations were associated with other organ involvement. Clinical manifestations were: abdominal pain (n = 6), vomiting (n = 3), and fever (n = 3). Elevated pancreatic enzyme was noted in all cases. All patients were treated by high doses of glucocorticoids. The outcome was favorable in five patients, and one patient died.

Conclusion

Pancreatitis may be the presenting manifestation of SLE. Its pathogenesis is often multifactorial. The outcome is usually favorable with corticosteroids.     

Hémophilie A acquise. Étude d’une série rétrospective monocentrique de 39 patients

Purpose

Acquired haemophilia A (AHA) is a rare bleeding disorder, due to the presence of an inhibitor directed against factor VIII (FVIII). About 50% of the AHA are idiopathic, while the remaining 50% are related to an underlying disorder or condition (autoimmune diseases, malignancies, postpartum, etc.).

Patients and methods

We report on a monocentric retrospective cohort of 39 patients with AHA. Data were collected and compared to recent published data.

Results

Thirty-nine patients were admitted for AHA between 1993 et 2011. Mean age at diagnosis was 71.3 years, and we noted a marked male predominance. Although the majority of patients presented a bleeding event at diagnosis (94.9%), the hemorrhagic mortality was low (2.6%). On the contrary, immunosuppressive morbidity and mortality were high in this elderly population. There was a clear correlation between initial FVIII inhibitor titer and complete remission delay. We did not identify prognostic factor for global survival.

Conclusion

AHA is a rare but potentially fatal disorder. Rapidity of diagnosis and treatment initiation is crucial. Morbidity and mortality, particularly of infectious cause, due to immunosuppressive treatment, should lead to consider other available therapeutical options.     

Péricardite récidivante : traquer le mésotheliome péricardique primitif

Introduction

Most of recurrent pericarditis are idiopathic and only 15 to 20% have a specific diagnosis. Primary pericardial mesothelioma is a rare cause of recurrent pericarditis. Diagnosis can be challenging and antedates patient's death in only 10 to 20% of cases. Histology of mesothelioma and immunohistochemistry are mandatory for the diagnosis. Median of survival before using pemetrexed was about 6 months after diagnosis.

Case report

We report the history of a 64-year-old woman for which repeated biopsy for recurrent pericarditis was necessary to diagnose a primary pericardial mesothelioma. The first biopsy had only found mesothelial hyperplasia.

Conclusion

This case report highlights the necessity of repeat pericardial biopsy in the case of adverse outcome.     

Antibiotic Therapy for Appendicitis in Patients Aged ≥80 Years

Purpose

Although many patients receive antibiotic therapy for appendicitis, it is unclear if this treatment can be administered to elderly patients. We aimed to assess the outcomes of antibiotic therapy for appendicitis in elderly patients aged ≥80 years.

Method

During this 4-year study, we enrolled 26 elderly patients who initially received antibiotic therapy. Of these, 3 were suspected to have complicated appendicitis. Antibiotic therapy consisted of second-generation cephalosporin and metronidazole that was administered for 4 days with a 24-hour fasting period. We evaluated the rates of treatment failure and recurrence.

Results

Mean age was 83.5 years, and 57.7% (15/26) of patients had comorbidities. One patient (4.8%) failed to respond to antibiotic therapy and underwent subsequent appendectomy. During the median follow-up period of 17 months, 5 patients (20%) experienced recurrence; 3 underwent appendectomy and 2 received a new course of antibiotics.

Conclusion

Antibiotic therapy without surgery may be a safe and effective treatment for appendicitis in selective patients aged ≥80 years. This is a good treatment option in patients with high operative risk.     

Réactivation d’une infection à parvovirus B19 chez une patiente infectée par le VIH

Introduction

Infection by human parvovirus B19 (erythrovirus B19) is common and usually asymptomatic during childhood conferring lasting protection against a new infection. Parvovirus B19 infection may cause erythema infectiosum (5th disease) and aplastic crisis. Secondary symptomatic parvovirus B19 infection in the same patient is rare and its physiopathology is not always clear.

Case report

A 48-year-old HIV-infected female patient presented within 5 years two acute episodes of parvovirus B19 infection although her CD4 cells count was above 500/mm³. Absence of specific antibodies production after the first episode and persisting parvovirus viremia suggested viral reactivation rather than re-infection. During the second episode, specific antibodies were produced.

Conclusion

Similarly to most DNA viruses, parvovirus B19 reactivation is possible in HIV-infected patients while effectively treated by antiretroviral therapy.     

Impacto del 18F-FDG PET/TC en el abordaje terapéutico del cáncer de pulmón no microcítico

Introduction

Disease stage is the most important prognostic factor in lung cancer, and optimal staging is important to determine the best therapeutic option. FDG-PET/CT has demonstrated its value in early stage non-small cell lung cancer (NSCLC) but there is still insufficient data to define its role in other stages.

Hypothesis

Information provided by FDG-PET/CT has an impact on the therapeutic management of patients with NSCLC.

Methods

A retrospective review was made of patients who underwent FDG-PET/CT between January 2008 and December 2010 for the diagnosis of NSCLC. Clinical stage before and after FDG-PET/CT and information about any change in therapeutic decision due to information provided by FDG-PET/CT were collected. Using pathologic evaluation as the gold standard, sensitivity, specificity, and positive and negative predictive values for CT and FDG-PET/CT were calculated.

Results

Of the 522 patients diagnosed of NSCLC, FDG-PET/CT was performed in 246 (47.1%). In 85 cases (34.6%) FDG-PET/CT led to stage migration. Treatment was modified in 60 patients (24.4% of all FDG-PET/CT performed), avoiding a futile thoracotomy in 13 cases (5.2%), and allowing treatment with curative intent in 26 (10.5%). Out of 90 patients (36.5%) evaluated as stage iii by CT staging, FDG-PET/CT modified the therapeutic approach in 36 (40%). For the 133 cases (54%) with pathological assessment of the mediastinal lymph nodes, sensitivity, specificity, positive predictive value and negative predictive value were 0.57, 0.64, 0.48 and 0.72 for CT, and 0.68, 0.86, 0.75 and 0.81 for FDG-PET/CT.

Discussion

Our data support previous reports that FDG-PET/CT is essential in the staging process not only for patients with potentially operable NSCLC but also for stage iii patients, as demonstrated by our data.     

Micro-angiopathie thrombotique avec anticorps anti-ADAMTS 13 révélant une fièvre Q aiguë

Introduction

Q fever can commonly mimic systemic diseases, leading to several immunological manifestations. Thrombotic micro-angiopathies manifest as a spectrum of related disorders in the form of thrombocytopenic purpura and hemolytic uremic syndrome.

Case report

We report a 77-year-old woman, who presented an acquired thrombotic microangiopathy with renal expression associated with the presence of anti-ADAMTS 13 antibodies, which occurred during an acute infection by Coxiella burnetii (acute Q fever).

Conclusion

Auto-immune disorders are well-known in chronic or acute Q fever but to our knowledge, this is the first reported observation of thrombotic microangiopathy with anti-ADAMTS 13 antibodies.     

Gastroentérite à éosinophiles

Purpose

Eosinophilic gastroenteritis is a rare and heterogeneous disorder characterized by eosinophilic infiltration of one or more layers of the gastrointestinal tract. Although it can involve any part of the gastrointestinal tract, the stomach and the proximal small bowel are the most common sites of involvement. Clinical features depend on which layer and site are involved. We report eight cases of eosinophilic gastroenteritis.

Methods

We conducted a retrospective review of consecutive adult cases diagnosed with eosinophilic gastroenteritis from 1990 to 2010. The diagnosis was established by histologic examination of endoscopic biopsy or operative specimen or by the presence of eosinophilic ascites.

Results

Eight patients (three men, five women) were diagnosed with eosinophilic gastroenteritis during the study period. Three out of the eight patients had a history of allergy. All patients had gastrointestinal symptoms. The most common symptoms were abdominal pain, vomiting, weight loss and ascites. Seven patients (87.5%) had hypereosinophilia. Seven patients had involvement of the subserosa and one of the mucosa. Four patients were treated with oral prednisolone. The symptoms in all the patients subsided within one month. The remaining four patients improved spontaneously. Four of our patients were followed-up for at least 2 months (11 to 68 months). A single patient presented a relapse.

Conclusion

Eosinophilic gastroenteritis should be suspected in patients having gastrointestinal discomfort along with peripheral eosinophilia. Definitive diagnosis requires histological demonstrations of eosinophilic infiltration of the gastrointestinal wall or high eosinophilic count in ascites fluid.     

Anévrismes infectieux de l’aorte thoracique : présentation de 7 cas et revue de la littérature

Purpose

Infectious aortic aneurysms are rare conditions, being responsible of 2% of aortic aneurysms. Most published results are surgical case series concerning infected abdominal aorta. In this retrospective study, we assessed clinical features and outcome of patients presenting infectious thoracic aortic aneurysms.

Patients and methods

Diagnosis was based upon a combination of imaging evidence for thoracic aorta aneurysm and evidence for an infective aetiology including a culture of a causative pathogen, or a favourable outcome with anti-infective therapy. Retrospective case series.

Results

Six men and one woman were included, with a mean age of 66 years. All the patient presented at least one cardiovascular risk factor or atherosclerosis localisation. Fever (71%) and chest pain (42%) were the most common clinical presenting manifestations. The causative pathogens were: Staphylococcus aureus (N = 1), Salmonella enteritidis (N = 3) and Candida albicans (N = 1). The contrast-enhanced computed-tomography disclosed an aneurysm whose diameter reached more than 50 mm (N = 5), that increased rapidly in size (N = 5), or presented an inflammatory aspect of the aortic wall (N = 4). Management was both medical and interventional: surgery (N = 3) or endoluminal repair (N = 4). Outcome was favourable in six patients; one patient died from aneurysm-related complications.

Conclusion

Clinical manifestations revealing an infectious thoracic aneurysm are variable. Diagnosis should be considered in patients presenting a rapidly-growing aneurysm, especially in the presence of elevated acute phase reactants. Endoluminal repair constitutes a treatment option. The role of FDG-PET for diagnosis and follow-up remains to be defined.     

Intestinal Blood Flow in Patients With Chronic Heart Failure : A Link With Bacterial Growth,Gastrointestinal Symptoms,and Cachexia

Background

Blood flow in the intestinal arteries is reduced in patients with stable heart failure (HF) and relates to gastrointestinal (GI) symptoms and cardiac cachexia.

Objectives

The aims of this study were to measure arterial intestinal blood flow and assess its role in juxtamucosal bacterial growth, GI symptoms, and cachexia in patients with HF.

Methods

A total of 65 patients and 25 controls were investigated. Twelve patients were cachectic. Intestinal blood flow and bowel wall thickness were measured using ultrasound. GI symptoms were documented. Bacteria in stool and juxtamucosal bacteria on biopsies taken during sigmoidoscopy were studied in a subgroup by fluorescence in situ hybridization. Serum lipopolysaccharide antibodies were measured.

Results

Patients showed 30% to 43% reduced mean systolic blood flow in the superior and inferior mesenteric arteries and celiac trunk (CT) compared with controls (p < 0.007 for all). Cachectic patients had the lowest blood flow (p < 0.002). Lower blood flow in the superior mesenteric artery and CT was correlated with HF severity (p < 0.04 for all). Patients had more feelings of repletion, flatulence, intestinal murmurs, and burping (p < 0.04). Burping and nausea or vomiting were most severe in patients with cachexia (p < 0.05). Patients with lower CT blood flow had more abdominal discomfort and immunoglobulin A–antilipopolysaccharide (r = 0.76, p < 0.02). Antilipopolysaccharide response was correlated with increased growth of juxtamucosal but not stool bacteria. Patients with intestinal murmurs had greater bowel wall thickness of the sigmoid and descending colon, suggestive of edema contributing to GI symptoms (p < 0.05). In multivariate regression analysis, lower blood flow in the superior mesenteric artery, CT (p < 0.04), and inferior mesenteric artery (p = 0.056) was correlated with the presence of cardiac cachexia.

Conclusions

Intestinal blood flow is reduced in patients with HF. This may contribute to juxtamucosal bacterial growth and GI symptoms in patients with advanced HF complicated by cachexia.     

Growth rates of small abdominal aortic aneurysms assessed by computerised tomography – A systematic literature review

Background

Most current evidence examining abdominal aortic aneurysm (AAA) growth is based on ultrasound surveillance.

Objective

This review aimed to systematically analyse studies which have assessed small AAA growth using computed tomography (CT) to monitor outcome.

Method

Studies investigating small AAA expansion rates using CT images were identified by searching the PubMed database and hand searching article reference lists. Eligible studies must have focused on monitoring small AAA growth using CT and included patients with baseline AAA diameters <55 mm for which growth rates were reported.

Results

Ten studies including 845 patients met eligibility with average baseline AAA diameters ranging from 36.2 to 50.5 mm. AAA growth was assessed using axial (n = 1), orthogonal (n = 2), anterior to posterior (n = 4), and unspecified (n = 3) measurement methods. One study reported the reproducibility of their assessment method. Mean AAA diameter growth rates ranged from 2.6 to 5.2 mm/year. Factors reported to be associated with increased AAA expansion included: large AAA thrombus size (n = 3 studies), large baseline AAA diameter (n = 2), high AAA wall stress, elevated plasma concentration of matrix metalloproteinase-9 and presence of carotid artery disease (n = 1 study each). Factors reported to be negatively associated with AAA growth included presence of diabetes mellitus and chronic limb ischaemia (n = 1 study each).

Conclusion

Many currently reported studies assessing small AAA growth on CT fail to report consistent use of reproducible measurement methods. CT offers the opportunity to assess orthogonal diameter and perform central reading which could be an advantage of this form of imaging.