Hématome rétropéritonéal spontané : cause rare de choc hémorragique

A spontaneous retroperitoneal haematoma is an uncommon cause of haemorrhagic shock. We report a case of spontancous rupture of a renal angiomyolipoma resulting in haemorrhagic shock in a 52-year-old woman. The renal tumor was recognized by sonography and diagnosed by CT-scan. Renal angiography was performed, but embolization was not successful. During the surgical procedure, nephrectomy was required because of persistent bleeding, related to disseminated intravascular coagulation. Outcome was uneventful. Diagnosis and treatment of renal angiomyolipoma are discussed. The Lenk's triad, consisting of acute lumbar pain, symptoms of internal bleeding and lumbar tumefaction, is the usual clinical picture of retroperitoneal haemorrhage. The kidney is the most frequent cause and renal angiomyolipoma is the most frequent benign tumor. Renal angiomyolipoma is either isolated or associated with tuberous sclerosis in up to 20 per cent of patients. Diagnosis is suggested by sonography and confirmed by CT-scan. Renal angiography, performed in haemodynamically stable patients, shows the origin of bleeding and allows embolization. Considering the frequent bilaterality of angiomyolipoma, surgery should be as conservative as possible in order to preserve renal function.     

Sciatiques zostériennes parésiantes précédant l'éruption cutanée. À propos de trois observations

Nous rapportons trois cas de sciatique zostérienne avec atteinte motrice. Le déficit moteur a précédé l'éruption cutanée typique. Le diagnostic a été confirmé par les données sérologiques et l'étude du LCR. Dans deux cas, le déficit a persisté à moyen terme (1 à 3 mois). Les facteurs favorisants, notamment une immunodépression, doivent être recherchés systématiquement. Un diagnostic et un traitement précoces pourraient permettre d'en améliorer le pronostic. La recherche d'anticorps ou d'ADN viral dans le LCR peut en faciliter le diagnostic, mais ces recherches peuvent rester négatives.We report three cases of herpes zoster sciatica with motor loss preceding the typical skin lesions. Serological tests and cerebrospinal fluid examination established the diagnosis. Two patients had residual motor loss after 1 and 3 months, respectively. Immunodepression and other risk factors should be looked for routinely. Early diagnosis and treatment may improve the prognosis. Tests for antibodies or viral DNA in cerebrospinal fluid can be helpful, although negative results do not rule out the diagnosis.     

Pharmacocinétique de la bupivacaïne administrée par voie péridurale ou sous-arachnoïdienne pour césarienne réglée

Twenty ASA 1 pregnant women at term, undergoing elective Caesarean section were included in this study. They were randomly assigned to one of two groups, receiving either a spinal or an epidural anaesthesia. Before induction, in order to prevent hypotension, all patients were given an i.v. infusion of 1000 ml of Ringer-lactacte and a subcutaneous injection of ephedrine 30 mg. They were positionned on the operating table with a 15° left lateral tilt. Spinal anaesthesia was performed with hyperbaric bupivacaine 0.5 p. cent (0.08 mg · cm⁻¹ of height). Epidural anaesthesia was obtained with a bolus dose of 0.5 p. cent plain bupivacaine, followed by a continous infusion through the epidural catheter until the level of surgical block reached T6 bilaterally. Bupivacaine was assayed in plasma by high performance liquid chromatography (HPLC). Following pharmacokinetic parameters of bupivacaine were determined : Cmax (maximal concentration), Tmax (time to reach maximum), AUC (area under curve), Cl (total plasma clearance), Vz (volume of distribution during the elimination phase), T1/2 (elimination half-life). Bupivacaine concentration was also measured in samples obtained at birth from umbilical vein and umbilical artery. The mean dose of bupivacaine used was 12.8 ± 0.6 mg in the spinal group and 118.6 ± 17.8 mg in the epidural group. The time of onset of surgical anaesthesia was significantly shorter with spinal anaesthesia (7.6 ± 4.4 vs 31 ± 11.1 min ; p < 0.01). The sensory block had a longer duration in epidural group (223.2 ± 15 vs 291 ± 13.8 ; p < 0.001). The first demand for postoperative analgesia occurred significantly earlier in spinal than in epidural group (172 ± 101 vs 442 ± 144 min ; p < 0.01). Nevertheless, the total amount of analgesies administered did not differ between the two groups. The number of patients who developed hypotension, as well as the Apgar score and acid-base status of the neonates at birth, were similar in the two groups. There was no significant difference in the quality of analgesia achieved with either spinal or epidural anaesthesia. The degree of maternal satisfaction was evaluated with a visual analogic scale (0–10) and was similar in the two groups. After spinal anaesthesia, the maximal plasma concentration of bupivacaine was significantly lower (p < 0.05) than in the epidural group, where it was close to the threshold of toxicity. The pharmacokinetics of bupivacaine has not been assessed by numerous studies, especially in the case of spinal anaesthesia. In this study, the Tmax in the spinal group was shorter than in the epidural group (p < 0.05), because of continuous epidural administration of bupivacaine. The prolonged elimination half-life of bupivacaine after epidural administration and its significantly lower plasma clearance in the epidural group might result either from the prolongation of absorption after the end of the perfusion or from a non linear absorption kinetics. The confirmation of the latter hypothesis requires further studies in order to determine whether hepatic enzymes which metabolize bupivacaine are susceptible of being fully saturated in some circumstances.     

Hématomes des surrénales et héparine

The diagnosis of adrenal haemorrhage complicating heparin therapy is often delayed, despite computed tomography (CT). Moreover, its pathogenesis is not clear. Adrenal haemorrhages are often seen in cases where there is no unduly excessive anticoagulation, and can be accompanied by a paradoxical thrombosis of the central adrenal vein. Symptoms usually occur within the first 8 to 12 days after starting heparin. The difficulty in establishing the diagnosis stems from the fact that symptoms are rather nonspecific: abdominal pain and backache, nausea, vomiting, lethargy, weakness, hypotension, hyperpyrexia. To confirm the diagnosis, both hormonal proof of adrenal failure and anatomic evidence of haemorrhage must be found. Early CT scans may show the haemorrhage. Several possible causes have been put forward to account for these adrenal haemorrhages. The degree of anticoagulation did not seem to be a prerequisite, 30 to 50% of patients showing no evidence of other bleeding or coagulation tests outside the therapeutic range. Capillary fragility of old age might be a factor. Stress would seem to be an important factor predisposing to adrenal haemorrhage. Many authors consider the paradoxical central vein thrombosis as a result of the haemorrhage rather than its cause, whereas other conclude the opposite. Unfortunately, to date coagulation studies are often incomplete; platelet counts were missing in most reports published before 1985. Since that date, a heparin induced thrombosis-thrombocytopaenia syndrome (HITTS), in which thrombosis may occur in any vascular bed, has been recognized with increasing frequency. Nine cases of adrenal haemorrhage associated with HITTS have been reported. It seems highly likely that a proportion of cases of heparin-related adrenal destruction are due to HITTS.(ABSTRACT TRUNCATED AT 250 WORDS)     

Détresse respiratoire aiguë révélant une leptospirose

The respiratory manifestations of leptospirosis are usually begnin. A case is reported of anicteric leptospirosis with serious pulmonary affection. The clinical symptoms, the radiological manifestations and haemodynamic investigation were suggestive of an acute respiratory distress by non-haemodynamic pulmonary oedema. In accordance with other authors, one would be justified in including this acute respiratory failure as part of the acute respiratory distress syndrome of the adult (ARDS).