Le lymphangiome kystique rétropéritonéal récidivant chez l’adulte

Cystic lymphangioma is a rare benign vascular tumor that may arise in various sites, revealed at any age. Abdominal locations represent less than 10% of the cases preferentially involving the mesentery. The retroperitoneal site is less frequent. The authors report the case of a 30-year-old woman who was admitted for an abdominal mass that appeared over the last one year. In her past, she was operated for a cystic mass and the anatomopathologist concluded it to be a cystic lymphangioma. Abdominal scan showed a retroperitoneal cystic mass. Surgical exploration revealed a retroperitoneal cystic tumor. Anatomopathologic examination concluded it to be a cystic lymphangioma. The cystic lymphangioma is a benign malformative tumor of the lymphatic system, its diagnosis requires a histological confirmation. Surgery is the best curative treatment with complete excision, the prognosis is excellent.     

Lymphangiome kystique rétropéritonéal

The cystic lymphangioma is a vascular tumor that arises at the expense of lymphatic vessels. It is a rare and benign dysplasia that occurs mainly in children. Adult forms are rare. Its expression is mainly cervical or axillary, with a few locations in the abdominal cavity. We report the case of a patient who presented with cystic lymphangiomas located in the retroperitoneal region. Various clinical aspects, diagnosis and treatment were studied.     

La fibrose rétropéritonéale idiopathique

Retroperitoneal fibrosis (RPF) is a rare disease characterized by the presence of fibro-inflammatory tissue around the aorta entrapping the adjacent structures. RPF can be idiopathic or secondary to many disorders. The physiopathology is unknown but can be part of the spectrum of IgG4 related diseases. Imaging studies and inflammatory markers are essential for initial evaluation and follow-up. Biopsy is usually not recommended. The first line of treatment is corticosteroids associated or not with immunosuppressive drugs. In case of ureteral obstruction with renal failure, ureteral stent placement or nephrostomies are recommended. Initial response to treatment is usually good but relapses are frequent.     

Sténose de l’artère rénale à distance d’une dénervation rénale pour HTA résistante

The onset of renal artery stenosis following a renal denervation is rare and occurs in the first few months after renal denervation. We report the onset of renal artery stenosis a long time after the renal denervation for resistant hypertension. This is a 74 year-old patient who stopped smoking in 1980 and who was treated for dyslipidemia with a revascularized coronary artery disease in 2011, a well-stabilized peripheral arterial disease since 2001, a stable asymptomatic carotid atheroma and a good kidney function. His hypertension known since 1995 became resistant. After the control of renal arteries by angio-CT scan, he had a renal denervation in October 2012. His blood pressure decreased 3 months later confirmed by self-blood pressure monitoring (SBPM) and ambulatory blood pressure monitoring (ABPM) with a CT scan with a non-significant renal artery stenosis in January 2014. He remained normotensive under treatment until July 2015 but his hypertension became uncontrolled at the end of 2015 then resistant and severe confirmed by SBPM in April 2017, despite a 5-drug antihypertensive treatment associated to atorvastatin and clopidogrel confirmed by SBPM in April 2017. A left post-ostial renal artery stenosis with decrease in size of left kidney and cortex as compared to 2011 was detected at CT and treated by angioplasty. It was associated with a rapid decrease in blood pressure but unfortunately a new increase related to a restenosis occurred at the end of 2017, which justified a new angioplasty. Discussion about the etiology and the management of this renal post-denervation late stenosis.     

Vascularites cérébrales associées aux infections

Infections are a frequent cause of cerebral vasculitis, important to diagnose because a specific treatment may be required. Infection-associated vasculitis can be caused by angiotropic pathogens (varicella zoster virus, syphilis, aspergillus). They can be associated with subarachnoidal meningitis (tuberculosis, pyogenic meningitis, cysticercosis). They can appear contiguously to sinuses or orbital infection (aspergillosis, mucormycosis). Finally, they also may be due to an immune mechanism in the context of chronic infections (hepatitis B virus, hepatitis C virus, human immunodeficiency virus). Cerebral vasculitis are severe conditions and their prognosis is directly linked to early recognition and diagnosis. Infectious causes must therefore be systematically considered ahead of cerebral vasculitis, and the appropriate investigations must be determined according to the patient's clinical context. We propose here an update on the infectious causes of cerebral vasculitis, their diagnosis modalities, and therapeutic options.     

Vascularites rétiniennes et maladies systémiques

Retinal vasculitis (RV) is an inflammation of retinal blood vessels that can be associated with uveitis or be isolated, and can induce vascular occlusion and retinal ischemia. Visual acuity can be severely affected in case of macular involvement or neovessel formation. The diagnosis relies on fundoscopy and fluorescein angiography. Systemic diseases may be associated with RV, the most frequently encountered are Behçet's disease, sarcoidosis or multiple sclerosis, all predominantly associated with venous involvement, whereas systemic lupus erythematosus and necrotizing vasculitis are less frequently observed and predominantly associated with arterial or mixed vasculitis. Treatments are usually aggressive in order to preserve a good visual acuity and to reduce retinal inflammation and chronic ischemia. Steroids, immunosuppressive drugs, retinal laser photocoagulation, intravitreal anti-VEGF injections are usual treatments and more recently, anti-TNFalpha monoclonal therapeutic antibodies have been shown to be very successful.     

Fréquence de l’hypertension résistante aux traitements et indication à la dénervation rénale

ObjectiveTo evaluate in hypertensive patients followed in a specialized hypertension unit, the prevalence of subjects uncontrolled despite triple therapy including a diuretic. The aim is to estimate the percentage of hypertensive patients with an indication to renal denervation.MethodFrom a database of computerized medical records of a unit specialized in hypertension, it was extracted 144 consecutive cases of subjects treated and followed for at least 1 year and having had a home pressure monitoring (HPM) on treatment, and if necessary a work-up for a secondary hypertension. The blood pressure (BP) was evaluated in office by automated method (after 2 and 8 minutes) and with HPM (average of three measurements in the morning and evening for three consecutive days).ResultsThe population has the following characteristics: age 62 with 26% over 70 years, treated dyslipidemia (39%), treated diabetes (11%), adrenal hypertension treated medically (14%), severe renal failure (3%). The means of treatment are: a monotherapy (33%), bitherapy (35%), triple therapy (17%), quadritherapy (7%), pentatherapy or more (1%), spironolactone (45%), thiazide diuretics (49%). The uncontrolled hypertension was observed in 26% if the BP is evaluated with HPM, in 52% if the BP is evaluated at the office after 2 minutes of rest and 7% if the BP is evaluated after 8 minutes of rest (P < 0.01). In patients treated with at least a tritherapy in association with a diuretic, an uncontrolled hypertension was observed in 5% if the BP is evaluated with HPM. Failure to control for the SBP is the cause of 80% of resistant hypertension.ConclusionThe frequency of resistant hypertension is 5% of hypertensive patients followed in a specialized hypertension unit when guidelines are applied in the case of uncontrolled hypertension. These results indicate that the indication for renal denervation affects only a small percentage of patients treated for hypertension.     

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.