[An unusual case of duodenal sarcoidosis]. / Sarcoïdose duodénale: à propos d'un cas.

INTRODUCTION: Sarcoidosis is a systemic granulomatous disorder of unknown aetiology. It may rarely affect the gastrointestinal tract. CASE REPORT: We reported a 54-year-old woman with a delayed diagnosis of duodenal sarcoidosis. She presented with gastric and right upper abdominal pain associated with vomiting and marked weight loss. Abdominal computed tomographic scan showed non-compressive retroperitoneal lymph nodes and histological examination revealed non-caseating epithelioid granulomas typical of sarcoidosis. Diagnosis of duodenal sarcoidosis was obtained at the third gastroscopy. The patient's condition improved quickly with corticosteroid therapy. CONCLUSION: Gastrointestinal sarcoidosis should be looked for in patients with digestive symptoms and another sarcoid localisation. Furthermore, it is important to repeat gastroscopy to confirm diagnosis because treatment improved most patients.

[Non-inferiority trial used in venous thromboembolic disease. A warily interpretation is necessary!]. / Essais de non-infériorité dans la maladie thromboembolique veineuse. Une lecture critique est nécessaire!

INTRODUCTION: Equivalence trials are actually frequently used to prove non-inferiority in anticoagulant therapy. Equivalence trials consist to demonstrate that two treatments are not too much different. This difference has to be under a margin previously determined. The margin corresponds to an efficacy loss that is defined to be acceptable, in accordance to the advantages due to the new treatment. The aim of this work is to explore the equivalence trial published in the thromboembolic disease by focus on the non-inferiority margin used. METHODS: We identified published equivalence trials in the venous thromboembolic disease, by a systematic search in Medline. We calculated the efficacy loss by reference with the value of the smallest effect size of the standard treatment compared to placebo. RESULTS: We found 9 equivalence trials used in venous thromboembolic disease. The mean value of the efficacy loss was 434%, and the median value was 357%. Eighty-five percent of the values of the efficacy loss were above 100%. DISCUSSION: Eighty-five percent of the equivalence trials conclude to equivalence despite a complete efficacy loss of the effect of the standard treatment compared to placebo. The results of equivalence trials should be interpreted warily. The corresponding non-inferiority margin should be chosen more rigorously and by reference with the value of the smallest effect size of the standard treatment compared to placebo.

[Diagnosis of venous thrombosis and/or pulmonary embolism by determination of d-dimers using ELISA. Review based on a study of 80 consecutive patients hospitalized in an emergency unit]. / Le diagnostic de la thrombose veineuse et/ou de l'embolie pulmonaire par le dosage des D-Dimères ELISA. Mise au point à partir d'une étude portant sur 80 patients consécutifs hospitalisés dans un service d'urgence médicale.

The sensitivity and specificity of an ELISA method (Fibrinostika Fbdp Organon Teknika) for assay of D-dimers in the diagnosis of deep vein thrombosis and/or pulmonary embolism was studied in 80 consecutive patients seen at an emergency unit. Fifty-six of the patients presented clinical signs of deep vein thrombosis. Diagnosis was confirmed in 26 of the 56 patients with a D-dimer level above 370 ng/ml (sensitivity 92.3%) and 370 ng/ml for 13 of 30 patients with a negative venous ultrasound Doppler examination (specificity 43.3%). The positive predictive value was 58.5% and the negative predictive value was 87%. There was a significant difference in the level of D-dimers between distal and proximal deep vein thrombosis. In 40 cases with suspected pulmonary embolis, either alone or with suspected deep vein thrombosis, diagnosis was made in only 4 of 9 with a highly or intermediately probable ventilation/perfusion scan. D-dimer level was always above 3,000 ng/ml. Coupling the ELISA dimer test with noninvasive explorations improves negative predictive value but can also avoid invasive explorations (venography, pulmonary angiography) in certain patients. A D-dimer test as sensitive as the ELISA test and as rapid as the latex test remains to be described.

[Triple association: extramembranous glomerulonephritis, renal adenocarcinoma and splenic hamartoma. Apropos of a case]. / Triple association: glomérulonéphrite extramembraneuse, adénocarcinome rénal et hamartome splénique. A propos d'un cas.

We report the case of a 36 year old woman who presented a renal cell carcinoma, associated to a membranous nephropathy as a paraneoplastic syndrome. The concomitant association with a splenic hamartoma was probably fortuitous. Five years after nephrectomy, the patient was asymptomatic and her proteinuria was very low. We studied in the literature 93 cases which reported a such association between cancer, nephrotic syndrome and membranous nephropathy. Carcinoma of the lung and adenocarcinoma of the gastrointestinal tract are the most frequently implicated. This association can occur at every age and more often in men (75%) than in women. The survival is directly linked to the evolution of the cancer. Proteinuria and membranous nephropathy can totally disappear after surgical resection of the carcinoma. The glomerular injury is mediated by immune complexes composed at least in part of tumour associated antigens. The development of several types of glomerular injury in patients with carcinoma have been described but membranous glomerulonephritis is the most commonly observed.

[Cytoplasm antibodies of polynuclear neutrophils in Wegener's granulomatosis and systemic vasculitis]. / Anticorps anticytoplasme des polynucléaires neutrophiles dans la granulomatose de Wegener et dans les vascularites systémiques.

In retrospective and prospective studies the sera of 442 patients recruited from an Internal Medicine department were examined by acetone indirect immunofluorescence and immunoblot in search of anti-neutrophil cytoplasm antibodies (ANCA). Twenty-three patients had Wegener's granulomatosis, and 419 had various control diseases including connective tissue diseases, vasculitis and granulomatosis. The sera from 100 healthy blood donors were used as controls. Among the 23 patients with generalized (n = 15) or localized (n = 8) Wegener's granulomatosis (active in 21/23), the indirect immunofluorescence test was positive in 92 percent of those with the generalized form and in 62 percent of those with the localized form. Nine of the 13 sera examined by immunoblot (69 percent) were positive (31 +/- 57 kDa bands). On the other hand, the sera from 38 (6.9 percent) patients with control diseases were positive at immunofluorescence: vasculitis (14 cases, 50 percent), connective tissue diseases (4 cases, 14.3 percent) and miscellaneous diseases including 3 neoplasms (10 cases, 35.7 percent). Only 6 of these 28 sera showed a 1/100th titer of ANCA. The sera of all healthy controls were negative. The sensitivity of ANCA for Wegener's granulomatosis at all stages was 72.2 percent, and its specificity 94.4 percent. This study confirms the value of ANCA as third diagnostic criterion of Wegener's granulomatosis, after the clinical and histological criteria.

[Clinical study of 12 cases of malignant non-Hodgkin's lymphoma of the orbital region]. / Etude clinique de 12 lymphomes malins non-hodgkiniens de la région orbitaire.

Over an 8-year period in the Departments of Hematology, Ophthalmology and Internal Medicine of our hospital, 12 cases of orbital and adnexal malignant non-Hodgkin's lymphoma were reported. Diagnostic elements varied, including local tumefaction, watering eyes, uveitis, and unexplained, long-term fever. Nine patients had primary paraocular lymphomas involving either orbital structures, the lacrimal gland or the eyeball, but after appropriate staging, the disease was found to be disseminated in 5; the 3 other cases were secondary orbital lymphomas. Intermediate or high grade histological types were predominant (9 patients) in our series. Radiation therapy, alone or combined (5 patients) with chemotherapy, was administered in 8 cases; other treatments consisted of chemotherapy (2 cases) or steroids (2 cases). Evolution was poor, with only 4 patients surviving at 34-180 months of follow-up. The main prognostic factors were tumor stage and histological grade. The clinical characteristics of this group are compared to those reported in the literature.

[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.