Hepatic granulomatosis in a patient with Graves' disease.

We report a case of granulomatous hepatitis in a patient with hyperthyroidism resulting from Graves' disease. A 30-year-old man presented with massive weight loss, jaundice, tachyarrhythmia and goitre. Liver function tests showed mild cytolysis and cholestasis and massive hyperbilirubinaemia. The echogram of liver and bile ducts was normal and no infection was found. A liver biopsy revealed a mixed cytolytic and cholestatic hepatitis with intralobular epithelioid granulomas. No specific cause was identified, and sarcoidosis and primary biliary cirrhosis were ruled out. The outcome was favourable with antithyroid therapy and short-term glucocorticoid therapy, and the patient was totally free of symptoms after 2 years. To our knowledge, this is the first case of granulomatous hepatitis to be reported in association with Graves' disease. The clinical evolution of the liver disease paralleled the evolution of hyperthyroidism.

[Painless infarction in antiphospholipid syndrome]. / Infarctus indolore au cours du syndrome des antiphospholipides.

The authors report a rare case of myocardial infarction secondary to coronary thromboses caused by the antiphospholipid syndrome. The relations between the cardiac pathology, especially the coronary disease, and antiphospholipid antibodies are recalled. The importance and methods of monitoring the anticoagulant therapy are emphasised.

[Inflammatory pseudotumor of the intestine caused by necrotizing vasculitis in the course of Horton disease]. / Pseudo-tumeur inflammatoire de l'intestin par vascularite nécrosante au cours d'une maladie de Horton.

The authors report a case of giant-cell arteritis involving the digestive tract, revealed by a subocclusive syndrome. It appeared to be an unusual pattern according to the location, the tumour aspect and the histologic appearance of a periarteritis nodosa type. The digestive involvement and the histologic appearance are discussed in a review of the literature, as well as the link with the periarteritis nodosa.

[Digestive arterial obstructive diseases in three young women]. / Artériopathies oblitérantes digestives chez trois jeunes femmes.

The authors report three cases of severe intestinal ischaemia occurring in young women (age 29-44), all of them being smokers. In all cases, intestinal ischaemia was recognized lately and lead to death within two years. The occlusive arterial lesions concerned nearly exclusively the intestinal arteries. Microscopic lesions were heterogeneous and non-specific. In a case, an occlusive intimal fibrosis was noted; in another case, fibrosis of the media and the adventitia was observed; and in the last case, the lesions were suggestive of thromboangiitis obliterans. The authors advocate for the systematic recording of cases of intestinal ischaemia in young women, in order to identify the risk factors and pathogenic features of this rare condition.

[Chronic fatigue syndrome: a critical review]. / Le syndrome de fatigue chronique: une revue critique.

The term "chronic fatigue syndrome" (CFS) applies to a condition of unknown aetiology characterized clinically by an association of subjective symptoms, the most constant being an invalidating tiredness. The diagnostic criteria in current use do not permit to isolate an homogeneous subgroup among patients consulting for chronic asthenia. In the present state of research no infectious or immunological cause has been demonstrated conclusively, although a persistent enterovirus or herpesvirus type 6 infection or a state of chronic immune activation seem to play a role in some cases. Patients who fulfill the criteria of CFS present with psychiatric overmorbidity, essentially depressive, and in 50% of the cases with the mental disorders preceding CFS. The various theoretical models linking CFS to psychopathology are discussed, and finally the syndrome is regarded as a social construction reproducing or renovating the neurasthenia of the late 19th century. There is no specific treatment of CFS, but antidepressants, cognitive-behavioural therapy and perhaps certain immuno-modulators can be useful. The future lines of research should endeavour to isolate a subgroup of patients with prolonged asthenia after a recognized episode of infection and to identify the immunological, psychological and behavioral characteristics of this particular group as well as their reciprocal interactions.

[Thyroid disease and multiple autoimmune syndromes. Clinical and immunogenetic aspects apropos of 11 cases]. / Pathologie thyroïdienne et syndromes auto-immuns multiples. Aspects clinique et immunogénétique à propos de 11 observations.

The authors report eleven cases of multiple auto-immune syndrome, concerning a total of 15 different auto-immune diseases. This study suggests that auto-immune thyroid disorders (Graves' disease or hypothyroidism resulting from Hashimoto's thyroiditis) are a common feature of multiple auto-immune syndromes, while antithyroid antibodies are constant among our patients. Sjögren's syndrome is also very prevalent, and seems to be non-randomly associated with auto-immune thyroid disorders, a fact which suggests common aetiological factors. Among other auto-immune disorders, the antiphospholipid syndrome has been diagnosed twice. A genetic predisposition to multiple auto-immune syndrome is obvious, as shown by a familial history of auto-immune disorders (found in more than half of the cases), and a predominant HLA phenotype, B8 and/or DR3. The authors plead for a systematic enquiry for multiple auto-immune syndrome in patients with auto-immune thyroid disorders and a family history of auto-immune disorders.

[Enterovirus infections and systemic clinical manifestations with prolonged inflammatory syndrome: association with a persistence of specific IGM antibodies]. / Entérovirose et manifestations cliniques systémiques avec syndrome inflammatoire prolongé: association avec une persistance des anticorps IGM spécifiques.

We report 9 cases of enteroviral infection associated with systemic inflammatory disease (including 4 cases of vasculitis, 1 case of periarteritis nodosa, 1 case of Sharp's syndrome). We then reviewed 36 cases of enteroviral infection with persistent IgM antibodies diagnosed in the virology laboratory in a 6-year period: among them 11 cases were found to present with subacute or chronic inflammatory disease. We conclude that enteroviruses might be important triggers of systemic inflammatory disease.

[Thyroid pathology and multiple autoimmune syndrome: clinical and immunogenetic aspect, apropos of 11 cases]. / Pathologie thyroïdienne et syndrome auto-immun multiple: aspect clinique et immunogénétique, à propos de 11 cas.

The authors report 11 cases of multiple autoimmune syndromes. Autoimmune thyroid disorders and Sjogren's syndrome seem to be non-randomly associated and might share a genetic predisposition linked to HLA phenotype B8 DR3 and B12 DR4.

[Antiprothrombinase and myocardial infarction. Apropos of 2 cases]. / Antiprothrombinase et infarctus du myocarde. A propos de deux observations.

Among the thrombotic events associated with a circulating anticoagulant of the antiprothrombinase type, myocardial infarction is exceptionally reported, which justifies the presentation of two cases. In both patients, myocardial necrosis occurred some time after the antiprothrombinase was discovered, and there was nothing special in its clinical features. No obvious atherosclerotic lesion and no image suggestive of vasculitis were found at coronary arteriography, which suggested that the antiprothrombinase played a predominant role in the genesis of infarction. Relationships between antiprothrombinase, arterial thrombosis (particularly of the coronary arteries) and the presence or absence of systemic lupus erythematosus (SLE) are discussed. As observed in thrombosis of other arteries, it is not certain that the presence of SLE constitutes an additional risk factor, except in cases with unquestionable vasculitis or if the treatment of SLE requires prolonged corticosteroid therapy. On the other hand, the appearance of an antibody directed against phospholipids is not necessarily related to the presence of SLE; in fact, this antibody itself might be a risk factor of myocardial infarction, as has recently been suggested.

[Vitiligo in multiple autoimmune syndrome: a retrospective study of 11 cases and a review of the literature]. / Le vitiligo au cours des syndromes auto-immuns multiples: étude rétrospective de 11 observations et revue de la littérature.

PURPOSE: The occurrence in the same patient of three or more autoimmune diseases defines multiple autoimmune disease. Multiple autoimmune disease is an unusual condition in which dermatological autoimmune diseases and especially vitiligo have an important place. METHODS: We examined retrospectively 11 cases of multiple autoimmune diseases associating vitiligo. We studied the clinical characteristics of vitiligo and those of the associated autoimmune disorders. RESULTS: Type III multiple autoimmune disease was diagnosed in all the 11 cases observed. Autoimmune vitiligo was the first autoimmune disorder observed in seven cases and was bilateral, symmetrical and acrofacial in eight cases. Autoimmune thyroid disorder was associated in ten cases. Our data confirms the important association between vitiligo and thyroid autoimmune disorders. CONCLUSION: The predominant female ratio and the acrofacial topography of skin lesions could predict association with others autoimmune disorders in patients with vitiligo.

[Screening for depression in patients with medical hospitalization. Comparison of two self-evaluation scales and clinical assessment with a structured questionnaire]. / Dépistage de la dépression chez les patients hospitalisés en médecine. Comparaison de deux échelles d'autoévaluation et du jugement des cliniciens à un questionnaire structuré.

The aim of this study was to determine, in a population of medical inpatients, the sensitivity, specificity, positive and negative predictive values of two self-rating depression scales, and of the physicians' judgment, compared to a structured interview derived from the Composite Interview Diagnostic Interview (CIDI) designed to assess the diagnosis of major depressive episodes. The setting of the study was a general internal medicine inpatient ward of a French university hospital. Patients between 15 and 75 were asked to fill, within the first week of their hospitalization, two self-rating depression scales: the Beck Depression Inventory - short form (BDI-short form), a 13-item scale with established reliability and validity; and the Center for Epidemiologic Studies-Depression Scale (CES-D), a 20-item scale designed for epidemiological use in the general population, recently translated in French. Patients were then interviewed by a psychologist, blind to the results of the self-rating scales, using a slightly simplified version of the depression section of the CIDI. The ward physicians' recognition of depression was assessed six months later by a careful chart review, conducted by an investigator blind to the results of depression scales and structured interview. One hundred consecutive patients were studied: 63% were women, mean age was 53.6 +/- 16.5 years. According to the results of the CIDI, the prevalence of current major depression was 29.7%, and the lifetime prevalence of major depression was 59.8%. The correlation between BDI-short form and CES-D was +0.81. BDI-short form proved to have a slightly better acceptability than the CES-D.(ABSTRACT TRUNCATED AT 250 WORDS)

[Intravascular malignant lymphoma (ex-malignant angioendotheliosis). 3 cases]. / Lymphome malin intravasculaire (ex-angioendothéliose maligne). 3 observations.

Malignant angioendotheliomatosis is an intravascular proliferation of tumour cells in the small arteries, veins and capillaries. Its lymphomatous origin has been proved recently by immunohistochemistry. It is a rare, generally rapidly fatal condition. Less than 150 cases have been reported in the literature. We report three cases. Long course fever with delayed neurologic disturbances were observed in the first case and long course fever, hyponatraemia, corticotropic and gonadotropic insufficiency in the second. The third case began with febrile meningo-encephalitis. Diagnosis was made at autopsy in the two first cases and on evidence from kidney needle-biopsy in the third. Clinical manifestations are polymorphic and frequently simulate vasculitis. Neurologic signs are the most common. Histologically, kidneys, skin, endocrine glands, lungs, muscles and most of the organs may be involved. Surprisingly lymph nodes, bone marrow and spleen are often free from disease. Current treatment is based on polychemotherapy. Earlier diagnosis of the disease should improve the prognosis as observed in our third patient.

[Silent myocardial ischemia in type 2 diabetes. Predictive value of intima-media thickness]. / Ischémie myocardique silencieuse chez le diabétique de type 2. Valeur prédictive de l'épaisseur intima-media.

CONTEXT: The carotid intima-media thickness (CIT) is correlated with the prevalence of cardiovascular diseases. We studied the relationship between the thickness of the carotid intima-media and the existence of myocardial ischemia, detected by scintigraphy in a population of type 2 diabetic patients without coronary antecedents. METHODS: We conducted repeated Doppler measurements of the CIT of primitive carotid arteries in 52 diabetic patients aged 49 to 75. All these asymptomatic patients, without coronary antecedents, diabetic for more than 10 years and exhibiting at least one cardiovascular risk factor, had undergone myocardial scintigraphy. RESULTS: The CIT was greater in the group with positive scintigraphies and is the best predictive factor of the presence of ischemia. For a CIT value < 0.55 mm, the negative predictive value of the CIT was of 77% with 80% sensitivity; in non-smokers the predictive negative value increased to 92% with 95% sensitivity. CONCLUSIONS: Reliable and reproducible, measurement of CIT correlates well with myocardial scintigraphy and could be an interesting alternative screening policy in asymptomatic, type 2 diabetic patients.