Thromboembolic events in inflammatory bowel disease.

GOAL OF THE STUDY: Inflammatory bowel disease (IBD) is associated with an increased risk of thromboembolic events (TEE) during outbreaks, increasing morbidity and mortality. The aim of our study was to specify the prevalence of TEE in IBD patients and to determine their epidemiological, clinical and evolutionary characteristics. MATERIEL AND METHODS: This is a retrospective study collecting all patients with IBD, who had a thromboembolic complication confirmed by imagery, between January 2012 and December 2018. RESULTS: One hundred patients with IBD were diagnosed during the study period. A TEE occurred in 6 patients (5.9%). These patients had an average age of 41 years, divided into 4 women and 2 men. Five patients had Crohn's disease and one patient had ulcerative colitis. The IBD was active in all patients. Five patients were already hospitalized and under preventive heparin therapy. Patients had deep venous thrombosis of the lower limbs in 3 cases, associated with pulmonary embolism in 1 case, cerebral venous thrombosis in 2 cases and pulmonary embolism isolated in 1 case. Thrombophilia investigations were negative in all patients. Evolution under medical treatment was favorable in 4 patients and fatal in 2 patients. CONCLUSION: In our study, the prevalence of TEE in patients with IBD was 5.9%. Thrombosis occurred during the active phase of IBD in all cases.

Subcutaneous phaeohyphomycosis caused by Amesia atrobrunnea in Kuwait.

The recently described genus Amesia encompasses four species but only Amesia atrobrunnea (=Chaetomium atrobrunneum) is known to be pathogenic to humans. Here, we describe a case of subcutaneous phaeohyphomycosis in Kuwait in an apparently immunocompetent patient diagnosed by direct microscopy of the infected tissue and culture. The identity of A. atrobrunnea was established by typical morphological characteristics and by sequencing of internally transcribed spacer (ITS) region and D1/D2 domains of rDNA. To the best of our knowledge, this is the first report documenting etiologic role of this species in causing a locally invasive subcutaneous infection.

Knowledge, perceptions and attitudes toward complementary and alternative therapies among Kuwaiti medical and pharmacy students.

OBJECTIVE: To determine the knowledge, perceived effectiveness and harmfulness of complementary and alternative medicine (CAM) modalities, general attitude and the need for education in the use of CAM therapies among medical and pharmacy students. METHODS: A descriptive and cross-sectional study was performed using a pre-tested questionnaire on a randomly selected sample of 250 students in Faculties of Medicine and Pharmacy, Kuwait University. Descriptive and logistic regression analyses were used in data analysis. RESULTS: The response rate was 88.4%. CAM usage was reported by 122 (55.2%) of students, and mostly associated with females (OR 4.4, 95% CI 1.7-11.3). Herbal products were the most commonly used (83, 37.6%). Knowledge about 11 CAM modalities was generally poor, even among the respondents who claimed to know them most. The knowledge about herbal products was significantly better among 58 pharmacy students (49.2%) than 32 medical students (31.4%) (OR 2.0, 95% CI 1.1-3.6). Massage, herbal products and prayer/Qur'an reciting were perceived as being the most effective, while cauterization as the most harmful. Attitude toward CAM was positive, with 176 (79.7%) believing that CAM includes ideas and methods from which conventional medicine could benefit. Lack of trained professionals and lack of scientific evidence were the most perceived barriers for CAM implementation. 198 (89.6%) admitted the importance of knowledge about CAM for them as future healthcare practitioners. CONCLUSION: The students acknowledged the need to be well educated about CAM to better advise their patients in the future.

[Hepatopulmonary syndrome: a complication of type 1 Gaucher disease]. / Syndrome hépatopulmonaire: une complication de la maladie de Gaucher de type 1.

Gaucher's disease is a not exceptional lysosomial disease in Tunisia. Type 1 is by far the most common one. Pulmonary involvement is considered to be rare in type 1 Gaucher's disease. Pulmonary hypertension, infiltration of the lungs with Gaucher cells, and severe hypoxemia due to intrapulmonary arterial-venous shunts, have been described in case reports and small case series. We reported the case of hepatopulmonary syndrome in a 14-year-old boy with type 1 Gaucher disease. The diagnosis of Gaucher disease was established, at 2 years age, by enzyme assay of leucocyte ß-glucosidase. The patient presented dyspnoea, digital clubbing and cyanosis of the lips. The arterial blood gas found severe hypoxaemia with PaO(2) at 56.9 mmHg. The diagnosis of hepatopulmonary syndrome, in our patient, was confirmed by demonstration of the intrapulmonary shunting using contrast-enhanced echocardiography and the technetium-99m-labeled macroaggregated albumin. The patient was treated by symptomatic measure, long term oxygen therapy because the insufficiency of the enzyme replacement therapy. Screening for hypoxemia in children with liver disease should be considered.

IgA anti-actin antibodies in celiac disease.

AIMS: The purpose of this study was to determine the sensitivity and specificity of IgA anti-actin antibodies (IgA-AAA) for celiac disease (CD), to investigate their usefulness as a marker of compliance in CD patients to the gluten-free diet (GFD), and to assess the relationship between their presence in the sera of CD patients and severity of intestinal mucosal damage. PATIENTS AND METHODS: A total of 182 patients with CD were studied: 63 patients were untreated; 50 patients were following a strict GFD; and 69 patients were non-compliant with a GFD. IgA-AAA was detected using a homemade enzyme-linked immunosorbent assay (ELISA). RESULTS: IgA-AAA showed a sensitivity of 41.3% and a specificity of 71.4% for a diagnosis of CD. In children, the frequency of IgA-AAA detection was lower in those following a strict GFD (23.1%) compared with untreated patients (39.4%) and those not complying with a GFD (32.5%). In patients following a strict GFD, IgA-AAA detection was significantly less frequent in children than in adults (23.1% vs. 58.3%, respectively; P<0.001). IgA-AAA was found in 17 out of 52 CD patients with total villous atrophy (32.7%), and in one out of 11 patients with subtotal villous atrophy (9%). CONCLUSION: IgA-AAA cannot replace anti-endomysium and anti-tissue transglutaminase antibodies in the diagnosis algorithm of CD, but it can serve as a reliable marker of severe intestinal mucosal damage in CD patients.

[Prognostic factors and survival of metastatic colorectal cancer in the Sousse University Hospital (Tunisia): comparative study of two treatment period of 200 patients]. / Facteurs pronostiques et survie des cancers colorectaux métastatiques au CHU de Sousse (Tunisie): etude comparative de deux périodes de traitement de 200 patients.

UNLABELLED: Between 1994 and 2005, 200 patients with metastatic colo-rectal cancers were treated in the Sousse CHU (Tunisia), we analysed two groups of patients, the group 1 was treated in the period after 1999 (N = 64), the group 2 was treated in the period between 1999 and 2005 (N = 136). PATIENTS AND METHODS: Mean age of the patients was 50 years, localisation of metastases was liver in 67.3% of cases, 23% of patients had multiple metastases, 44% of cases developed metastases after a median period of 11.4 months. All patients had received first line of chemotherapy, the regimen of chemotherapy was in the group 1, Fufol in the majority of cases (76%), the regimen of chemotherapy was in the group 2, simplified LV5FU2 associated to irinotecan in the majority of cases (83%), 28% of all patients received second line of chemotherapy. RESULTS: The median survival was 13.8 months in the group 1 and 19 months in the group 2. Overall survival rates at 2 years were 35% and 42% (p = 0.02) in group 1 and 2, respectively. Prognostic factors for a better survival using univariate analysis were: normal ACE (P < 0.01), normal liver analysis (P < 0.001), response after 3 cycles of chemotherapy (P < 0.0005), resection of liver metastases (P < 0.05). The multivariate analysis (cox model) revealed only one independent factor: radiologic response after 3 cycles of chemotherapy (P < 0.03). CONCLUSION: The prognostic of patients with metastatic disease is poor, although palliative chemotherapy after the recent advances and the use of new drugs have been shown to be able to prolong survival and to improve the quality of life over best supportive care. This study report amelioration of prognostic and survival of metastatic colorectal cancers in Tunisia.

[Primary digestive tract lymphoma in central region of Tunisia: anatomoclinical study and therapeutic results about 153 cases]. / Les lymphomes primitifs du tube digestif (LPTD) dans le centre tunisien: étude anatomoclinique et résultats thérapeutiques à propos de 153 cas.

Primary gastro-intestinal lymphoma (PGIL) is the most common type of extra-nodal non Hodgkin's lymphoma. Their clinical and histological presentations are heterogeneous depending on the site of the lesion. There is no consensus regarding the role of surgery and chemotherapy in the therapeutic approach. In our country epidemiology of the disease is unknown with IPSID being the most frequent type. We report anatomo-clinical features and prognostic factors of PGIL and compare intestinal to gastric forms in our region. This is a retrospective study of 153 cases of PGIL in adults diagnosed and treated in the department of medical oncology in Farhat Hached Hospital between 1994 and 2006. The median age was 52 years and the sex-ratio 2.1. Tumor sites were gastric (67%), intestinal (26%) and gastrointestinal (7%). Abdominal pain (87%) followed by vomiting and diarrhoea (37 and 15%) were the most common symptoms. Performance status (PS) < 2 was seen in 80% of patients, high grade lymphoma in 70.5% of cases and B phenotype was noted in 85%. MALT lymphoma accounts for 50% of cases, and IPSID for only 5% of PGIL. About 47.5% of cases were stage IE, 138 patients had chemotherapy with an objective response rate of 77%. Only 46% of patients had surgery (14 for surgical complication, 6 for residual tumor after chemotherapy and 22 to have histological diagnosis). The five-year overall survival (OS) was 62%. In high grade lymphoma patients favorable prognostic factors for OS included young age < or = 60 years, PS < 2, normal serum LDH, hemoglobin > 12 g/dL, B phenotype, localised stage (IE-IIE1), anthracycline-based chemotherapy regimen, achieving complete or partial response to induction chemotherapy and no relapse. In multivariate study only relapse and PS were significant prognostic factors for OS. In low-grade lymphoma patients, none of these factors had a significant correlation with OS: age < or = 60 years, PS < 2, stage (IE-IIE1), response to induction chemotherapy, relapse. Compared to gastric lymphomas, intestinal cases occurred at a younger age, frequently with diarrhoea, weight loss, and occlusion. They are more often high-grade, T phenotype and have locally advanced stage (IIE); surgery is more common in this group. We conclude that stomach is the main site of PGIL in our region, intestinal lymphoma is less frequent and IPSID has become rare. Recent progress in chemotherapy has allowed good therapeutic results with a conservative approach. Surgery may be performed in case of emergency or for residual lesions after medical treatment.

Scintigraphic findings in hungry bone syndrome following parathyroidectomy

La hipocalcemia prolongada tras paratiroidectomía, conocida como síndrome del hueso hambriento, es una complicación presente en 13–30% de pacientes tras cirugía paratiroidea. Presentamos el caso de una paciente de 48 años de edad con dolor óseo y múltiples tumores pardos como primera manifestación de hiperparatiroidismo primario por gran adenoma paratiroideo. Tras paratiroidectomía, la paciente presentó signos clínicos de hipocalcemia sugestivos de síndrome del hueso hambriento. Se describen las alteraciones radiológicas y gammagráficas observadas tras la paratiroidectomía(AU)

Prolonged hypocalcemia following parathyroidectomy, called hungry bone syndrome, is a common complication of parathyroid surgery seen in 13–30% of cases. In this article, we report the case of a 48-year-old woman with bone pain and multiple brown tumors as the first manifestation of primary hyperparathyroidism due to a large parathyroid adenoma. After parathyroidectomy, the patient presented clinical signs of hypocalcemia consistent with hungry bone syndrome. Scintigraphic and radiographic modifications following parathyroidectomy are described(AU)

Captopril renography as a prognostic factor in obstructive hydronephrosis with preserved renal function

El riñón hidronefrótico con una función renal diferencial mayor del 55% se define como supranormal. El significado de este hallazgo sigue siendo controvertido. En este artículo, los autores comunican un caso de función supranormal dentro de una hidronefrosis obstructiva. Se evaluaron las funciones diferenciales del riñón después de la administración de captropril y después de una pieloplastia. Se examina el papel de la renografía con captopril como un factor de prognosis para la cirugía(AU)

Hydronephrotic kidney with a differential renal function greater than 55% is defined as supranormal. The signification of this finding remains controversial. In this article, the authors reported a case of supranormal function in obstructive hydronephrosis. Differential renal functions were evaluated after administration of captopril and after pyeloplasty. The role of captopril renography as a prognostic factor for surgery is discussed(AU)

Captopril renography as a prognostic factor in obstructive hydronephrosis with preserved renal function.

Hydronephrotic kidney with a differential renal function greater than 55% is defined as supranormal. The signification of this finding remains controversial. In this article, the authors reported a case of supranormal function in obstructive hydronephrosis. Differential renal functions were evaluated after administration of captopril and after pyeloplasty. The role of captopril renography as a prognostic factor for surgery is discussed.

Scintigraphic findings in hungry bone syndrome following parathyroidectomy.

Prolonged hypocalcemia following parathyroidectomy, called hungry bone syndrome, is a common complication of parathyroid surgery seen in 13-30% of cases. In this article, we report the case of a 48-year-old woman with bone pain and multiple brown tumors as the first manifestation of primary hyperparathyroidism due to a large parathyroid adenoma. After parathyroidectomy, the patient presented clinical signs of hypocalcemia consistent with hungry bone syndrome. Scintigraphic and radiographic modifications following parathyroidectomy are described.

Corticomedullary mixed tumor of the adrenal gland.

A 34-year-old woman presented with weight gain, hirsutism, recent hypertension and secondary amenorrhea. Laboratory findings showed hypokalemia, elevated cortisol and androgen levels with normal urine metanephrines and normal aldosteronemia. Abdominal magnetic resonance imaging showed a right heterogeneous adrenal mass measuring 4 x 6 cm with mixed component of fat and adrenal tissue suggesting corticosurrenaloma. After right adrenalectomy, blood pressure normalized and hypokalemia resolved. In the postoperative course, the patient presented adrenal insufficiency treated with hydrocortisone hemisuccinate. Histological examination showed a single tumor mass composed of an admixed population of adrenal cortical and medullary cells. Immunohistochemical evaluation was positive for chromogranin A.

Diabetes mellitus as an early symptom of pancreatic cancer diagnosed three years later.

We present a case of a 40-year-old man with strong family history of diabetes. His pancreatic ultrasonography was normal at the discovery of his diabetes. Anti-pancreatic antibodies were negative. The patient was treated by insulin and continued to loose weight. His diabetes remained unstable during the follow-up. Three years later, a pancreatic adenocarcinoma was diagnosed which was locally advanced and could not be removed surgically. This observation argues among several mechanisms explaining diabetes in subjects with pancreatic cancer, in favor of tumor-derived diabetogenic substance and suggests that diabetes mellitus could reveal pancreatic cancer even in the presence of conventional risk factors of type 2 diabetes.

Role of the peritoneopleural pressure gradient in the genesis of hepatic hydrothorax. An isotopic study.

SUMMARY: Hepatic hydrothorax is defined as the development of significant pleural effusion in a patient with cirrhosis without primary pulmonary or cardiac disease. This complication is seen in 4-10% of patients with cirrhosis. The pleural effusion is a result of a direct passage of ascitic fluid into the pleural cavity through a defect in the diaphragm. We report two patients with posthepatitis cirrhosis presenting with a significant pleural effusion. The peritoneopleural communication was demonstrated by peritoneal scintigraphy. The role of the peritoneopleural pressure gradient is discussed.

Retroperitonial liposarcoma mimicking pheochromocytoma.

The authors report the case of a 46-year-old woman who presented with a 4 month history of paroxystic and recent hypertension accompagned by headaches, tachycardia and sweating. The patient had decreased appetite with epigastric discomfort and abdominal distension. Physical examination was initially normal with mainly normal tension and no abdominal or lombar mass in palpation. While hospitalised, she developed paroxystic crisis of flush, headaches and hypertension of 190/100 mmHg. Biological findings revealed hypokaliemia and normal kaliuria on 3 day samples, with normal glycaemia and normal creatininaemia. Hormonal investigation revealed elevated metanephrines (3 mg/24 hours). Magnetic resonance imaging showed an 11 cm x 8.5 cm retroperitoneal mass with an enhanced signal in T2, a hypotrophic non-functional left kidney and no adrenal adenoma. Clinical and hormonal features suggested a diagnosis of pheochromocytoma. After preoperative medication, open excision, including left radical nephrectomy and adrenalectomy, normalized the catecholamine urinary level, resolved hypokalemia, and improved hypertension. Pathologic examination revealed a well-differentiated liposarcoma, without any pheochromocytoma component, and left adrenal hyperplasia. The tumour cells were immunonegative for chromogranin A. No metastatic lesion was identified by thoraco-abdominal computed tomography.

Detection of M2 antimitochondrial antibodies by dot blot assay is more specific than by enzyme linked immunosorbent assay.

AIMS: The objective of our study was, in one hand, to determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ELISA and dot blot assay to investigate IgG M2 antimitochondrial antibodies (M2 AMA) and, on the other hand, to compare these results with those of indirect immunofluorescence technique (IIF). METHODS: Sera from patients suffering from primary biliary cirrhosis (PBC) (n=55), systemic lupus erythematosus (n=21), celiac disease (n=30) and blood donors (n=75) were analyzed. M2 AMA were detected by ELISA and dot blot using pyruvate dehydrogenase purified from porcine heart and by IIF on cryostat sections of rat liver-kidney-stomach. RESULTS: IIF was more sensitive (98%) than ELISA (93%) and dot blot (91%). The specificity of AMA for PBC using IIF, ELISA and dot blot reached 100%, 92% and 100%, respectively. The PPV of IIF, ELISA and dot blot was 100%, 93% and 100%, respectively. The NPV was 98% for IIF, 92% for ELISA and 91% for dot blot. CONCLUSION: Dot blot, using purified pyruvate dehydrogenase, had a higher specificity than ELISA and may be useful in confirming the specificity of AMA in cases of doubt with IIF.

[Papillary thyroid microcarcinoma presenting as cervical lymph node metastasis. Interest of tetrofosmin scintigraphy and lymph node thyroglobulin measurement]. / Microcarcinome papillaire de la thyroide révélé par des métastases ganglionnaires cervicales. Intérêt de la scintigraphie à la tétrofosmine et le dosage de la thyroglobuline ganglionnaire.

PURPOSE OF THE STUDY: Thyroid microcarcinoma presenting as cervical lymph node metastasis is common and it is associated in most cases with the papillary variety. Diagnosis of lymph node metastases from a thyroid microcarcinoma is not always easy, because a thyroid nodule may not be palpable. MATERIAL AND METHOD: In this work, the authors report two cases of papillary microcarcinoma presenting as cervical lymph adenopathy. RESULTS: The diagnosis was made preoperatively by Tetrofosmin scintigraphy and thyroglobulin measurement in the lymph node. CONCLUSION: Tetrofosmine scintigraphy is a performing exam but with a poor specificity. Lymph node thyroglobulin is a simple exam which is very sensitive and specific.

[Factitious Cushing syndrome: two case reports]. / Le syndrome de Cushing factice: deux observations.

INTRODUCTION: Search of corticosteroid use is an important precaution before any exploration of hypercorticism. Nevertheless, this use may be factitious leading to serious misdiagnosis and pitfalls. EXEGESIS: We report two cases of 29 and 60 years old male patients, referred for hypercorticism with patent features including metabolic and trophical signs. Laboratories findings revealed unelevated urinary cortisol values (40 and 27 microg/ day) in both cases with normal ACTH and normal plasmatic cortisol response to synacthène (32,5 and 35 microg/dl). Corticosteroid use, initially denied, was finally approved by the patients (hydrocortisone and dexamethasone for the first patient and betametasone for the second). So, they were assigned to psychiatric therapy. CONCLUSION: Our cases emphasize that corticosteroid misuse must be evoked in patients with unexpected hormonal assessment of pituitary adrenal axis despite patent clinical features of hypercorticism. Several specific tests are actually available for detect factitious Cushing syndrome. However, differential diagnostic remains difficult mainly with pseudo Cushing and cyclical Cushing syndromes.

Predictive factors of glucocorticosteroid treatment failure in severe acute idiopathic colitis.

INTRODUCTION: The purpose of our study was to determine clinical, biological or endoscopic factors that could predict glucocorticosteroid treatment failure in acute colitis. PATIENTS AND METHODS: Fifty-four Tunisian Caucasian patients with acute idiopathic colitis (ulcerative colitis in 53 patients, Crohn's colitis in 1 patient) have been evaluated. Non-therapeutic response was defined as over 6 bowel movements per day, blood visible to the naked eye in stools on the fifth day after admission or the development of a complication inducing a resort to surgery. Predictive factors were assessed using bivariate and multivariate analysis. RESULTS: Thirty-nine patients (72.2%) had no medical response. In univariate analysis, predictive factors of therapeutic failure were: male sex, tobacco, previous history of colitis attacks, bowel movements per day over seven at admission and on day three, and pulse rate over 90/mn, temperature over 38 degrees C, systolic blood pressure below 11 on day 3 and on day 5 after admission. In multivariate analysis, bowel movements over seven per day on day 3 of hospitalization and male sex independently predicted a failure of glucorticosteroid treatment. CONCLUSION: Bowel movements per day over seven on day 3 of hospitalization and male sex were the independently predictive factors of failure of glucocorticosteroid treatment.