Toxoplasmose médullaire au cours de l’infection à VIH

We report the case of an atypical localization of a spinal cord “toxoplasmic abscess”. The 46-year-old patient, HIV-1 positive, was admitted for acute urine retention and gait disorders. MRI revealed a T12–L1 medullary lesion suggesting a tumoral, inflammatory and infectious pathology. The radiological aspect and immunosuppression lead to the initiation of a treatment against Toxoplasma gondii, following the same treatment principles as for cerebral toxoplasmosis. The diagnosis can only be proved by data from autopsy or surgical biopsy, but toxoplasmosis PCR on CSF seems to be an interesting alternative to confirm the diagnosis. According to the literature, PCR is not sensitive enough as a diagnostic tool. Improvement after treatment supported the diagnosis confirmed by PCR.     

Dénutrition au stade pré-dialytique de l''insuffisance rénale chronique

Protein-caloric malnutrition is not uncommon in pre-dialysis patients at an advanced stage of evolution. Malnutrition is associated with a poor prognosis during the first months of dialysis.The decline of spontaneous alimentary intake with the progression of renal failure results from the retention of anorexigenic substances. Metabolic acidosis and abnormalities in nutrient metabolism may also contribute to malnutrition. A sufficient protein-caloric intake must be offered to the pre-dialysis patients, adapted to the degree of CRF. Persistent malnutrition despite regular medical and dietetic follow-up is a valuable criterion for initiating of dialysis.     

Métabolisme des nutriments au cours de l'insuffisance rénale chronique

The suppression of renal metabolic function is responsible of metabolic acidosis, uremic toxicity and endocrine disturbances. Subsequent abnormalities of protein metabolism are:

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  an increase in muscle proteolysis related to acidosis and hypercortisolemia;

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  a decrease in hepatosplanchnic amino acid utilization which is responsible for reduced protein synthesis and ureagenesis as well as abnormal amino acid release in the absorptive phase.

Main abnormalities in energy substrate metabolism are: insulin resistance, impaired blood glucose regulation, and reduced triglyceride clearance. Energy metabolism is also characterized by an increase in energy expenditure and an accelerated fasting behaviour. Hypermetabolism together with increased protein turnover are responsible for an increase in nutritional requirements: 35–40 kcal/kg.day and, in dialysis patients, 1,2–1,4 g protein/kg.day.     

La glycémie postprandiale : du normal au pathologique

Postprandial glucose excursions contribute to both chronic sustained hyperglycaemia and acute glucose fluctuations from peaks to nadirs. Lessons from physiology indicate that non diabetic persons spend half of their life in postprandial states. However, in normal subjects, postmeal glucose increments remain limited in duration and magnitude. Progression from normal stages to frank diabetes is a stepwise process. The first step from normal to impaired glucose tolerance (IGT) is characterised by a glycaemic deterioration limited to the postprandial period. The second step from IGT to diabetes corresponds to a loss of glycaemic control at the end of the night (dawn phenomenon) followed by a progressive increase in fasting glucose and by an additional deterioration of postmeal glucose excursions. This progression is explained by three main disorders (the biological triumvirat): a relentless defect in β-cell function, an insulin resistance that progresses over the time course of the disease, and an hepatic glucose overproduction that reaches a peak at the end of the overnight fast. These observations indicate that the monitoring of glycaemic disorders in type 2 diabetes should include the three parameters of the “glucose triad”: the HbAlc, the fasting glucose and the postmeal values. More generally, the assessment of glycaemic profiles over daytime is helpful for choosing and tailoring the treatments according to whether the prandial or the basal hyperglycaemia is predominant.     

Mécanismes de la dénutrition au cours de l'insuffisance respiratoire chronique

The study of the mechanisms of denutrition during chronic obstructive pulmonary disease is useful because this common evolutive complication has severe functional consequences and is associated with a poor prognosis, irrespective of respiratory functional status. Conversely, renutrition improves the prognosis in these patients. Adaptation to hypoxia, the basis of which is oxygen conformance, is described. Denutrition during chronic obstructive pulmonary disease is linked to the imbalance arising from increased energy expenditure and inadequate food intake. The origins of the imbalance are discussed. The clinical implications of knowing the mechanisms of denutrition are set out and perspectives for both experimental and applied research are proposed.