Superselective embolisation of bilateral superior vesical arteries for management of intractable hematuria in context of metastatic bladder cancer.

Hematuria due to locally advanced or metastatic bladder cancer is a common condition and is often a management problem. Percutaneous embolisation is a mini-invasive option to handle this situation. We report a case of a patient with a metastatic bladder cancer and who presented with an abundant hematuria and severe anemia. After failure of endoscopic resections and "flush" of radiotherapy haemostatic and refusal of cystectomy by the patient, he was treated by superselective embolisation of bilateral superior bladder arteries with excellent immediate results. The technique is safe and effective in the short term. The long-term effectiveness requires further investigation.

[Epidemiological, clinical and therapeutic features of hepatocellular carcinoma in cirrhotic patients]. / Aspects épidémiologiques, cliniques et thérapeutiques du carcinome hépatocellulaire chez le cirrhotique.

BACKGROUND: Hepatocellular carcinoma (HCC) is the most frequent primitive hepatic tumor, the fifth most common cancer in the world,and the third highest cause of cancer-related mortality. The presence of cirrhosis is the main risk factor. AIM: To describe the epidemiological, clinical and therapeutic features of HCC. METHODS: Retrospective study including all the patients with HCC occurring in cirrhotic liver followed in the gastroenterological department of Charles Nicolle hospital between 1997 and 2009. RESULTS: A hundred and one patient were enrolled; 64 men and 37 women with a median age of 65.4 years (31-88 years). Cirrhosis was due to viral hepatitis B or C in 25.7% and 62.2% of cases respectively and was classified Child Pugh A, B and C in 30.7%,50.5% and 18.8% of patients respectively. HCC was inaugural in most cases (68.3 %) and it was revealed by a tumoral syndrome in 38.6% of cases, by decompensation in 22.7% and was discovered during systematic screening when cirrhosis was already known in 19.8% of cases. Diagnosis of HCC was non invasive, relying on imaging and alphafetoprotein in most cases (95%). 84 patients(83.2%) had an advanced HCC, with vascular or extra hepatic spread in 58 (57.5%) of them. Treatment was curative in 14 cases, based on surgical resection in one case and percutaneous ablation in 13 cases.Six patients received transarterial chemoembolization as a palliative treatment. In 71 patients, only symptomatic treatment was given. The median survival time was 11 months. CONCLUSION: In the majority of the cases, HCC was diagnosed at an advanced stage and treatment was only symptomatic.

[Percutaneous vertebroplasty for pain relief in patients with osteoporotic spine fractures]. / Efficacité antalgique de la vertébroplastie percutanée dans les fractures vertébrales ostéoporotiques.

BACKGROUND: Percutaneous vertebroplasty (PVP) is an interventional radiology technique where pathological vertebral bodies are filled with acrylic cement. This method is used to strengthen the vertebral body and reduce pain in certain diseases involving the vertebrae such as osteoporosis. AIM: To evaluated PVP in symptomatic osteoporotic vertebral fractures after failure of conservative management. METHODS: Between November 2008 to December 2009, PVP was performed for osteoporotic vertebral fractures i 12 consecutive patients in a single institution. Medium term (3 days and 15 days post PVP) and long term follow up (1 month and 3 months post PVP) consisted in the evaluation of residual or secondary pain using Huskisson's visual analogue scale. RESULTS: A total of 20 vertebrae were treated. Mean follow up was 80 days (30-90 days). Significant symptomatic improvement (p=0.002) was noted with pre PVP pain score of 7.4 (±1.6 ), 3 days post PVP score of 4.1 (±2.1), 15 days post PVP score of 1.8 (±1.1), 1 month post PVP score of 1.22 (±1.06) and 3 months post score of 1.4 (±1.14). CONCLUSION: PVP appears to be an effective technique in the treatment of symptomatic osteoporotic vertebral fractures with approximately 94% of satisfactory results in the short and medium term period.

Association of serum levels of aggrecan ARGS, NITEGE fragments and radiologic knee osteoarthritis in Tunisian patients.

OBJECTIVES: Proteolytic degradation of aggrecan is a hallmark of the pathology of osteoarthritis. The aim of this study was to develop enzyme-linked immunosorbent assay (ELISA) to quantify the serum levels of specific aggrecan fragments generated by aggrecanases-mediated cleavage. We investigated the relationships between these two aggrecan degradations fragments and urinary CTX-II levels. METHODS: The competitive ELISAs employ a polyclonal antibody raised against the aggrecan fragments containing two neoepitopes NITEGE(373)and (374)ARGSVI. We measured serum levels of ARGSV and NITEGE in 125 women with knee osteoarthritis (mean±SD age of 53.6±7.6 years, mean±SD disease duration of 3.6±3.8 years), and 57 women age-matched controls. RESULTS: Aggrecan neoepitopes assays showed an intra- and inter-assay imprecision (CV) lower than 20% for both tests and good linearity. Median serum ARGSVI (by 18%; P=0.002), and NITEGE (36.4%; P<0.001) levels were significantly decreased in patients with knee osteoarthritis compared with controls. Minimal joint space width was negatively correlated with ARGSVI (r=-0.368, P=0.04) and NITEGE (r=-0.274, P=0.038) in knee osteoarthritis patients. Median urinary CTX-II levels were significantly increased by 39.5% (P=0.001) in knee OA patients compared with controls. CONCLUSION: Markers of degradation aggrecan were analyzed for the first time in an African osteoarthritis population. These markers can be used to monitor aggrecanase activity in human joint disease. Their combination with CTX-II can improve clinical investigation of patients with osteoarthritis patients.

[Spinal hydatidosis: diagnostic and treatment]. / Hydatidose vertébrale: approche diagnostique et thérapeutique.

Hydatidosis is a parasitic disease due to Echinococcus granulosus. Spinal hytatidosis is the most common form, characterized by high morbidity and mortality. It is often diagnosed only when neurological complications occur, due to the long clinical latency and the non specific nature of symptoms. Standard radiography may show lacunar, areolar abnormalities separated by irregular walls without clear boundaries. Magnetic resonance imagery can reveal hydatic abcess presenting typical liquid abcess and locoregional extension. Laboratory methods are of little assistance to the diagnosis. Complete surgical excision of the lesions remains the only curative treatment, in the same way as for malignant tumors. Surgical eradication of hydatic lesions is difficult, however. Indeed, the surgeon is guided by the macroscopic aspect, but the bone may be infiltrated by microvesicles without clear boundaries. It is now recommended to accompany surgery by medical treatment based on albendazole. Rapid diagnosis and treatment of spinal hyatidosis may yield long-term remission or even cure, especially in localized forms.

Vascular complications after pediatric kidney transplantation.

BACKGROUND: Vascular complications, especially those including the renal vein, remain a major cause of lost graft. AIMS: To evaluate retrospectively the incidence and management of vascular complications after pediatric renal transplantation and to assess possible risk factors and their effects on patient and graft. METHODS: A total of 82 consecutive renal transplants were performed in 79 patients at a single institution. The diagnosis of vascular complications was suspected in the presence of suggestive symptoms and confirmed by Doppler ultrasound and if necessary by a computed tomographic angiography. Urgent exploration was performed in all suspected cases. RESULTS: There were seven vascular complications (8,5%), including renal vein thrombosis in four patients, renal artery stenosis in one, and sural thrombophlebitis in two. The thrombosis of the graft vein which is the main complication occurred at mean 24 hours after renal transplantation. All these patients needed transplant nephrectomy after thrombosis event. In the remaining cases, the outcome was favorable even for the patient with transplant renal artery stenosis. CONCLUSIONS: Vascular complications are common and serious events affecting patient and graft survivals. A perfect surgical technique and rigorous radiological monitoring may result in decreased incidence and severity of these complications.

[Association of post-transplant lymphoproliferative disease and visceral leishmaniasis after kidney transplantation]. / Association d'un syndrome lymphoprolifératif et d'une leishmaniose viscérale après transplantation rénale.

Malignancies and opportunistic infections are frequently observed after solid-organ transplantation. Their occurrence strongly affects recipient survival. We report the case of a 29-year-old Tunisian kidney-recipient who was diagnosed simultaneously with post-transplant lymphoproliferative disease (PTLD) and visceral leishmaniasis (VL). Withdrawal of immunosuppressive therapy together with antiparasitic treatment using liposomal amphotericin B, and anti-CD20 antibodies medication resulted in cure of leishmaniasis and remission from PTLD. This case is of clinical interest because of the uncommon association of VL with PTLD after solid organ transplantation. It is also original by the favourable outcome of VL and PTLD, both known as life-threatening diseases. Also, it illustrates the predisposing role of immunosuppressive therapy in occurrence of opportunistic infections and malignancies after solid organ transplantation.

Primary hyperoxaluria type 1 in Tunisian children.

BACKGROUND: Primary hyperoxaliuria type 1 is an autosomal recessive disorder characterized by increasing urinary excretion of calcium oxalate, recurrent urolithiasis, nephrocalcinosis, and accumulation of insoluble oxalate throughout the body. This inborn error of metabolism appears to be a common cause of end stage renal disease in Tunisia. AIMS: To review the clinical, biological and radiological futures of primary hyperoxaluria type 1 and to correlate these aspects with the development of end-stage renal disease. METHODS: we retrospectively reviewed 44 children with Primary hyperoxaliuria type I who were treated in our department during a period of 15 years between 1995 and 2009. The diagnosis was established by quantitative urinary oxalate excretion. In patient with renal impairment, the diagnosis was made by infrared spectroscopy of stone or by renal biopsy. RESULTS: Male to female ratio was 1.2. The median age at diagnosis was 5.75 years. About 43 % of those were diagnosed before the age of 5 years. Initial symptoms were dominated by uraemia. Four patients were asymptomatic and diagnosed by sibling screening of known patients. Nephrocalcinosis was present in all patients. It is cortical in 34%, medullary in 32% and global in 34%. At diagnosis, twelve children were in end-stage renal disease (27%). Pyridoxine response, which is defined by a reduction in urine oxalate excretion of 60% or more, was found in 27%. CONCLUSION: In the majority of patients, the clinical expression of Primary hyperoxaliuria type 1 is characterized by nephrocalcinosis, urolithiasis and renal failure. Pyridoxine sensitivity is associated with better outcome.

[Management of postpartum vaginal haematomas by embolisation: two cases]. / L'embolisation radiologique dans le traitement du thrombus vaginal (à propos de deux observations).

Postpartum vaginal haematomas are a rare complication of delivery. The incidence of large haematomas is estimated at 1/4000 deliveries, and this complication can be life-threatening. We report two such cases. The diagnosis is suggested by shooting perineal pain with urinary tenesmus and vulvovaginal swelling or an unexplained haemorrhagic syndrome in the postpartum period. Rapid management is essential. Embolisation by interventional radiology is preferred to surgery. In the first case, arterial embolisation was performed after bilateral ligation of the hypogastric arteries failed. Arterial embolisation was the first-line treatment for the second patient. It was successful for both women.

First case of childhood Takayasu arteritis with renal artery aneurysms.

Takayasu arteritis is a large vessel systemic granulomatous vasculitis characterized by stenosis or obliteration of large and medium sized arteries. It commonly involves elastic arteries such as the aorta and its main branches. Renal artery involvement is rare and has not been reported in a child. We report a 12-year-old boy with Takayasu arteritis who developed severe hypertension, proteinuria, microscopic hematuria and renal dysfunction. Conventional angiography demonstrated aneurysms of both renal arteries and multiple microaneurysms of the superior mesenteric artery. This case report illustrates that the children with Takayasu arteritis can develop renal involvement resulting in hematuria, proteinuria and even renal failure.

[Perigenital hematoma. Diagnosis and management]. / L'hématome périgénital: diagnostic et prise en charge.

OBJECTIVES: Discuss the clinical aspects and the management of perigenital hematoma, a rare complication of delivery that can engage the vital prognosis. CASES: We report 4 cases of peri-genital hematomas recorded in the department C of obstetrics and gynecology, in the maternity center of Tunis. In two cases, the patients had only medical treatment and in the two others arterial embolisation was performed. CONCLUSION: The diagnosis is evoked in front of an unexplained hemorrhagic choc with perineal pain. Upon diagnosis, the patient must be rapidly managed associating resuscitation, surgery and angiographic embolisation.

Pseudoaneurysm of the splenic artery presenting with gastrointestinal bleeding.

Gastrointestinal bleeding from a pancreatic pseudocyst is a rare condition that is diagnostically and therapeutically challenging. A 78-year-old woman with a history of acute pancreatitis due to gallstones was hospitalized for abdominal pain and gastrointestinal bleeding. Gastroscopy revealed blood extruding from the papilla of Vater. A computed tomography scan revealed hemorrhage into a pancreatic pseudocyst. The patient was successfully treated by coil embolization.

[Experience of a multidisciplinary team in the management of superficial venous malformations: 99 cases]. / Les malformations veineuses superficielles et leur prise en charge par un comite multidisciplinaire: 99 cas.

BACKGROUND: Vascular malformations are heterogenous angiodysplasias. AIM: The aim of this work is to study the epidemiological and clinical features of venous malformations (VM) as well as their multidisciplinary management. METHODS: It is a retrospective study of patients having simple VM, seen at the multidisciplinary consultation of angiodysplasias of our hospital, over a 10 year period. RESULTS: This study included 99 patients having VM. A female predominance was noticed. Average age was 18.5 years. VM had mainly cephalic location. All VM were treated with percutaneous sclerotherapy. Aesthetic results were excellent in the cases of small VM size. CONCLUSION: VM are most frequent in cephalic region and cause aesthetic and functional handicaps. Percutaneous sclerotherapy is the treatment of choice for such a venous malformations, especially for small VM. VM are anomalies which can have serious complications. Their management has to be multidisciplinary in order to better precise the diagnosis and to take the adequate therapeutic decision.