[Gastro-intestinal tract tuberculosis: a little documented form of a too well-known infection]. / La tuberculose intestinale: une forme méconnue d'une infection trop connue.

In France, tuberculosis (TB) is still a health issue among underprivileged people and immigrants. We report a case of disseminated tuberculosis with intestinal involvement causing ill absorption and thus, making oral treatment impossible. Intestinal TB is often underrated and yet, malabsorption may lead to treatment failure or to developing antibiotic resistance. This type of tuberculosis must be systematically investigated when assessing the damage caused by tuberculosis and, more particularly, if there is any abdominal pain as well as clinical and biological signs of malabsorption. Parenteral antibiotherapy and nutrition must be systematically discussed.

[Ambroxol-induced immune hemolytic anemia]. / Anémie hémolytique immunoallergique due à l'ambroxol.

INTRODUCTION: Drug-induced immune hemolytic anemia is a rare cause of hemolytic anemia. CASE RECORD: A 68-year-old male patient developed an acute intravascular hemolysis with acute renal failure. Common causes of hemolysis were ruled out and the patient rapidly improved. An immune mechanism was confirmed by the positivity of the direct antiglobulin test with anti-IgA in the presence of ambroxol only, one of the drug the patient had received during 6 days before hospitalization. DISCUSSION: To our knowledge, this is the first report of ambroxol-induced immune hemolytic anemia. This case also underlined that the direct antiglobulin test should also be performed with anti-IgA to rule out any false negative.

Subclavian and axillary involvement in temporal arteritis and polymyalgia rheumatica.

PURPOSE: We describe 10 female patients with temporal arteritis (TA) and/or polymyalgia rheumatica (PMR) who presented with upper-extremity ischemia. PATIENTS, METHODS, AND RESULTS: Arm claudication or Raynaud's phenomenon was the initial manifestation of the disease in four cases, appeared with classical symptoms in one case, or occurred during decreasing corticosteroid therapy in five cases. Temporal artery biopsy was performed in nine patients and showed typical giant-cell granulomatous arteritis in seven cases. Angiograms in all cases showed multiple bilateral smooth stenoses, or obliterations of postvertebral subclavian and/or axillary arteries, or both. Symptoms always improved with corticosteroid treatment and none of the patients required reconstructive surgery, although angiography performed after stabilization did not show revascularization of occluded vessels. CONCLUSION: We conclude that large-artery involvement in TA and PMR affects most commonly the subclavian and axillary arteries, with a female predominance comparable to that in Takayasu's arteritis. Both these disorders should be considered in elderly women with occlusive disease of the upper extremities. Although response to steroid therapy was sufficient in our series to avoid surgery, we believe it is preferable to recognize large-artery involvement as early as possible and recommend performance of ultrasonic Doppler examination when any sign of oncoming ischemia or stenosis is observed.

[Subclavian and axillary arteritis in Horton's disease and rhizomelic pseudopolyarthritis. 10 cases]. / Artérites sous-clavières et axillaires au cours de la maladie de Horton et de la pseudopolyarthrite rhizomélique. 10 observations.

Ten patients aged from 60 to 73 years presenting with Horton's disease or polymyalgia rheumatica had arteritis of the upper limbs. Asymptomatic abolition of pulse in the upper limbs (1 case) or claudication at rest or exercise (9 cases) and/or Raynaud's phenomenon (5 cases) preceded (4 cases) or accompanied (1 case) the discovery of giant cell arteritis, or complicated the reduction or discontinuation of corticosteroid therapy. Diagnosis rested on the regular association of an inflammatory syndrome with multiple arterial tapered stenoses and/or arterial thrombosis in the post-vertebral subclavian, axillary or brachial arteries and, chiefly, on the demonstration (in 7 cases) of a giant cell granuloma at biopsy of the temporal artery. Corticosteroid therapy (1 mg/kg/24 h in 8 cases and 0.5 mg/kg/24 h in 2 cases) initially combined with anticoagulants in 4 cases resulted in rapid regression of ischaemic and systemic signs in all patients, thus avoiding surgical revascularization of the upper limbs.

[Para-aortic paraganglioma found by arteriography. Apropos of a case and review of the literature]. / Paragangliome para-aortique découvert en artériographie. A propos d'un cas et revue de la littérature.

A 53 years old man had an angiography for suspected renovascular hypertension (arteritis, renal insufficiency, duplex scanning). It showed a narrow right renal artery streched by a 45 mm mass arising from the adrenal. The computed tomography showed the tumor and the nuclear magnetic resonance imaging indicated a pheochromocytoma. The patient had no complain of headaches, palpitations or sweating. Biochemistry was normal except for a slight serum creatinin elevation and a non significant urinary noradrenaline level. A diagnostic of non functioning pheochromocytoma was made. The therapeutics consisted in a surgical ablation of the tumor and the right kidney (non functioning) and the patient became normotensive thereafter without treatment. The histologic feature was an aortico-sympathetic paraganglia, the adrenal was normal. Paraganglias are arising from the paraganglion system including chemodectoma and glomus jugulare tumor. Non functioning retroperitoneal paraganglias are uncommon: less than 50 in the literature between 1902 and 1992.

[The fate of patients with carotid stenosis. Comparative study, based on the literature, of their natural history and evolution under medical treatment or following endarterectomy]. / Devenir des patients porteurs d'une sténose carotidienne. Etude comparée, d'après la littérature, de leur histoire naturelle et de leur évolution sous traitement médical ou après endartériectomie.

The aim of therapy of carotid artery stenosis is to reduce the number of cerebral ischemic accident complications, but marked uncertainty exists at the present time as to the spontaneous course of these stenotic lesions and the efficacy of the different treatments proposed. After a transient ischemic accident (TIA) there is a 37% risk of a vascular accident (CVA) of a more definite type occurring within 5 years but only 1/4 of these patients die of cerebral complications, death in half of the cases being of coronary origin. Very rapid treatment with anticoagulants after TIA slightly diminishes the number of established cerebral ischemic accidents, but increases the risk of cerebral hemorrhage. Among the anti-aggregant agents, only Aspirin at high dosage (1 to 1.3 g/24 h) appears to be effective in preventing relapses of TIA and/or of CVA and/or on mortality which results from it. Carotid endarterectomy after TIA does not alter long-term survival, dependent on the increased cardiac mortality, but appears to reduce markedly the long-term recurrence rate of TIA and/or CVA. Globally, however, benefits of surgical treatment can be obtained only if post-operative cerebral mortality and morbidity are extremely low, conditions obtained in highly specialized centers only. Spontaneous course of angiographically detected asymptomatic stenosis shows, for a mean 4-year survival, a relatively low level of TIA (3,3 to 19%) and of CVA (0 to 12%) whatever the anatomic type of the stenosis. Prophylactic endarterectomy in practised hands has a low operative mortality (0 to 2%), a limited perioperative cerebral morbidity (1.3 to 4.5%) and a satisfactory later relapse rate of CVA (less than 5% at 4 years). These findings indicate comparable courses for spontaneous and treated cases globally, as well as with respect to cardiac mortality. In the absence of randomized trials it is a controversial point as to whether carotid surgery is superior to a spontaneous course in cases of asymptomatic stenosis.

[Comparative study of transcutaneous oxygen pressure and laser- Doppler flow in the feet of 15 healthy subjects]. / Etude comparative de la pression d'oxygène transcutanée et du flux laser-Doppler au niveau du pied chez 15 sujets sains.

Measurement of TcPO2 in arterial diseased patient is a reliable and reproductible method for evaluation in stages III and IV of the degree of tissue ischemia which can serve to establish the viable prognosis of the limb. One of the disadvantages of this technique is the relatively long time taken. By contrast the Doppler-laser, a more recently introduced technique, can be used to measure superficial cutaneous flow. One of its advantages is the rapidity of its instantaneous measurements. Before testing this technique in arterial disease sufferers it was felt to be of interest to determine the possible existence in the healthy subject of a correlation between TcPO2 and laser-Doppler flow. The study involved 15 healty subjects, 8 men and 7 women, with a mean age of 24.2 years. TcPO2 and laser-Doppler measurements were carried out in the fore-foot at 38 degrees and 44 degrees, under basal conditions and then after ischemia each time for 5 minutes, finally followed by a 10-minute 100% hyperoxia test. There was only a slight correlation at 38 degrees between the two methods and no correlation was found at 44 degrees. With oxygen therapy TcPO2 increased considerably and there was a nonsignificant decrease in laser-Doppler flow. In total, the two methods did not truly explore the same microcirculatory data and clinical studies would appear necessary to determine whether laser-Doppler flow measurements in the arterial disease patient may prove to be as useful as those of TcPO2.

[Re-permeation of deep venous thrombosis of the lower extremities: comparison between plethysmographic indices and phlebography scores. Preliminary results]. / Reperméation de la thrombose veineuse profonde des membres inférieurs: comparaison des indices pléthysmographiques et des scores phlébographiques. Résultats préliminaires.

A prospective study, now pursued, has the aim of determining anatomical features (permeability of deep venous trunks and/or development of a collateral venous circulation) related to improvement in plethysmographic indices and comparing these with phlebographic data. Twelve patients have been investigated by occlusive plethysmography and bilateral phlebography of lower limbs on the day of diagnosis, after 10 days of heparin therapy and after 6 months of antivitamin K anticoagulant treatment started on the 11th day. Whereas a progressive improvement in plethysmographic indices and phlebographic scores exists during the course of treatment, no correlation has been observed between plethysmographic indices and degree of phlebographic obstruction. This suggests that the emptying rate indices cannot be considered as an absolute criterion for the decision to discontinue anticoagulant therapy.

[Study of microcirculatory flow variations by laser Doppler velocimetry after cutaneous application of nitrated derivatives in normal subjects]. / Etude des variations du flux microcirculatoire par vélocimétrie Doppler au laser après application de dérivés nitrés cutanés chez le sujet sain.

The local microcirculatory effect of percutaneous nitrate derivatives was evaluated by determining flux by laser Doppler in 10 controls. The application of Lenitral cream under the recording probe produced a rapid (within a mean of 6.7 min) elevation in the flux, reaching a maximum in 20 min and returning to baseline values in 55 minutes. This vasodilatory effect was maximal in the richly vascularized zones, but remained limited to the site of application of the nitrate derivatives, being undetectable even at a short distance from the application zone.

[Immunogenetics of Horton's disease and of rhizomelic pseudo-polyarthritis]. / Immunogénétique de la maladie de Horton et de la pseudo-polyarthrite rhizomélique.

The etiopathogenesis of temporal arteritis and rhizomelic pseudo-polyarthritis still remains undefined. A genetic predisposition would seem probable in view of epidemiological data (higher frequency in white caucasian races and in certain countries), the existence of rare familial forms (25 families reported), and the significant increase in incidence in unconnected cases with HLA DR4 antigen (6 studies). Environment may intervene as a precipitating factor in the condition and the role of an infectious agent, to account for the seasonal incidence of this disorder and the rare existence of cases in non consanguineous couples, has been suggested but remains unproven. Disordered immune function probably plays an essential role in the creation of the vascular histological lesions characteristic of the condition. The disordered function involves cellular immunity (fall in OK T8. in blood) and especially humoral immunity with the very frequent presence of circulating immune complexes in the serum and deposition of immunoglobulins and complement at arterial wall level.

[Esophageal Abrikosov's tumor, preoperative diagnosis with echoendoscopy]. / Tumeur d'Abrikossoff oesophagienne, diagnostic préopératoire par écho-endoscopie.

Echo-endoscopic investigation provided the preoperative diagnosis in a case of oesophageal Abrikossoff's tumor. Characteristics of this rare tumor are described, and difficulties of etiologic diagnosis prior to histology underlined, using conventional exploratory examinations. Minimal surgery should be attempted for this exceptionally malignant tumor.

[Autotransplantation in the treatment of isolated dissection of the renal artery]. / L'autotransplantation dans le traitement des dissections isolées de l'artère rénale.

Isolated dissection of renal artery is uncommon; 150 cases were reported in the literature, whose 2/3 diagnosed during patient's life and 1/3 post mortem, during autopsy. From 1976 to 1988 4 cases of isolated dissection of the renal artery were diagnosed and treated in our Institution. Three men and one woman with age ranging from 39 to 46 yrs (mean age 41.75) were seen at our Institution for intense abdominal pain and blood hypertension (mean blood pressure 196.25/113.75 mmHg) of recent occurrence. In 2 cases angiography showed dissection of the left renal artery, with involvement of peripheral branches; in 1 case the dissection involved the right renal artery with complete occlusion of an upper pole branch and upper pole infarction; our youngest patients presented a bilateral dissection, limited to the main trunk on the right side and involving prepelvic and retropelvic branches on the left side. Surgical treatment consisted of renal autotransplantation in the iliac fossa after extracorporeal reconstruction of the arterial pedicule; a branched hypogastric graft was used in 3 patients; in the patient with bilateral dissection an hypogastric graft was used on the right side and a sapehenous graft on the left side (3 months later). Partial nephrectomy was also performed in the patient having right upper pole infarction. Histologic examination showed that dissection always started from lesions of the lamina media. All patient were alive from 6 to 48 months after renal revascularization, with normalization of blood pressure (mean BP 125/80 mmHg); postoperative angiographic control showed thrombosis of 2 small branches in 1 case and partial stenosis of 3 anastomoses in another patient.(ABSTRACT TRUNCATED AT 250 WORDS)

[Involvement of arterial trunks of the upper limbs in giant cell arteritis. Apropos of 7 cases]. / Atteinte des troncs artériels des membres supérieurs au cours de l'artérite à cellules géantes. A propos de 7 observations.

On 91 patients with temporal arteritis (TA) and/or polymyalgia rheumatica (PMR), we observed 7 females aged 62 to 73 years with upper extremities ischemia. Arm claudication and/or Raynaud's phenomenon were the initial manifestations of the disease in 2 cases, or appeared simultaneously with other symptoms in 2 cases, or complicated decreasing corticosteroid therapy in 3 cases. A temporal artery biopsy was performed on 6 patients with, in all of them, typical giant cell granulomatous arteritis pathology findings. Angiograms showed, in all cases, multiple bilateral smooth stenosis and/or obliterations of post vertebral subclavian arteries and/or axillary arteries. Symptoms always improved on corticosteroid treatment and no patient needed reconstructive surgery. In conclusion, large arteries involvement, which can occur in TA and/or PMR, affect in our experience most commonly the subclavian and axillary arteries, with female predominance as found in Takayasu's arteries. These disorders should be considered in cases of occlusive disease of the arms in elderly women and the response to steroids is usually adequate to eliminate the need for early surgical intervention. Early recognition of asymptomatic large artery involvement by Doppler evaluation, in all TA and/or PMR patients, and transient anticoagulant therapy might prevent vessels occlusions.