Reversible splenial lesion in auto-immune thyroid disease: a case report.

Reversible lesions of the splenium of the corpus callosum constitute a clinicoradiological syndrome that has been associated to various medical conditions. We report the case of a 47-year-old man who presented with encephalopathy associated to auto-immune thyroid disease in which a reversible splenial lesion was isolated. Although encephalopathy associated to auto-immune thyroid disease is characterized by variable radiological findings, it has only been once associated with a reversible splenial lesion.

[Lipoprotein (a) in liver diseases. Correlation between low levels and liver function]. / La lipoprotéine(a) dans les hépatopathies. Corrélation entre sa diminution et l'état fonctionnel du foie.

OBJECTIVES: To analyze the role of the liver function on the serum levels of lipoprotein(a) (Lp(a)), a lipoprotein considered to be a risk factor for atherosclerosis. METHODS: To measure the Lp(a) levels in patients with liver disease (n = 68) due to various causes and in patients with no liver disease and of similar age and sex-ratio (n = 62) and to analyze the relationship between Lp(a) levels on one hand and liver function and lipid and apoprotein levels on the other hand. RESULTS: Patients with liver disease had significantly lower levels of Lp(a). Lp(a) levels were significantly lower in patients with more severe liver disease (Child Turcotte classification) and significantly correlated with liver function tests, in particular those related to the microsomal function and the synthetic capacity of the liver (albumin, coagulation tests, apoprotein A-II). In patients with liver disease, mean Lp(a) levels were not significantly different between those with and those without chronic alcohol intake. CONCLUSIONS: Patients with liver disease have low levels of Lp(a) that are related to reduced synthetic capacity of this organ and are not linked to a specific cause of liver disease, in particular excess alcohol intake.

Liver injury related to amoxycillin-clavulanic acid: interlobular bile-duct lesions and extrahepatic manifestations.

We report eight cases of liver injury related to amoxycillin-clavulanate. Liver biopsy performed in seven patients revealed varying degrees of injury to interlobular bile ducts in all cases. Lesions included irregularity of the nuclei, vacuolization of the cytoplasm, lymphocytic infiltration, destruction and endothelialization of the bile duct epithelium. Ductopenia was not observed. In two patients liver injury was accompanied by prominent extrahepatic manifestations (acute interstitial nephritis in one and acute lacrimal gland inflammation and sialadenitis with prolonged xerostomia in the other). We conclude that interlobular bile-duct lesions of varying severity are a common feature in liver injury related to amoxycillin-clavulanate. Side effects of the drug include acute interstitial nephritis and sialadenitis.

Serum lipoprotein(a) in patients with diabetes mellitus.

OBJECTIVE: To investigate subjects with different types of diabetes mellitus regarding their serum levels of lipoprotein(a). High serum Lp(a) concentration is associated with a high risk of coronary heart disease. Diabetic patients are prone to developing coronary heart disease. RESEARCH DESIGN AND METHODS: The subjects were 66 type I diabetic patients, 100 type II diabetic patients treated with diet alone or diet combined with oral hypoglycemic agents, and 46 insulin-requiring type II diabetic patients. Subjects were compared with 142 nondiabetic outpatients. RESULTS: Subjects with insulin-requiring type II diabetes mellitus were found to have an increase both in serum Lp(a) concentration and in prevalence of serum Lp(a) concentration > 30 mg/dl compared with the other groups of diabetic patients and nondiabetic control subjects. A nonsignificant increase in the prevalence of coronary heart disease was also found in insulin-requiring type II diabetic patients. The levels of serum concentrations of Lp(a) were not significantly related to the degree of glycemic control, duration of diabetes, presence of macrovascular disease, or intake of female hormone therapy. High levels of Lp(a) in this group of diabetic patients could not be explained by the presence of albuminuria. CONCLUSIONS: Insulin-requiring type II diabetic patients have high levels of Lp(a). Chronic hyperinsulinemia might be an eventual causal factor.

The density, contour, and thickness of the pancreas in diabetics: CT findings in 57 patients.

Insulin has a trophic effect on pancreatic acinar tissue, so the pancreas might be expected to atrophy in persons who have diabetes. Accordingly, we analyzed the density, contour (smooth or lobulated), and thickness of the pancreas on CT scans of diabetic patients and compared the results with those in control subjects. The prevalence of pancreatic lobulation (incisurae deeper than 2 mm) and its correlation with age in diabetic and control subjects were determined. The thickness of the pancreas was measured at three levels (head, body, tail). Three groups of diabetic patients were examined: 20 insulin-dependent patients, 25 patients not treated with nor dependent on insulin, and 12 patients treated with but not dependent on insulin. A control group included 57 nondiabetic patients. The ages of the control subjects were similar to those of the diabetic patients. The statistical significance of the differences between groups of diabetic patients and control subjects was estimated by using Student's t test for the values of density and thickness and the chi 2-test for the prevalence of pancreatic lobulation. The density of the pancreas in diabetic patients and control subjects was not statistically different. Diabetic patients had increased lobulation of the pancreas. All parts of the pancreas tended to be smaller in diabetic patients, but the degree of reduction varied. It was modest in the patients not treated with insulin, pronounced in insulin-dependent patients, and intermediate in non-insulin-dependent, insulin-treated patients. Moreover, the size of the body was significantly reduced in all three groups, whereas the size of the pancreatic head was preserved in patients not treated with insulin. In conclusion, CT of the pancreas shows that although density in diabetic patients is normal, lobulation is increased. Reduction in size involves the body of the pancreas more than other parts of the gland and is more pronounced in insulin-treated diabetic patients. CT of the pancreas might be useful to predict which diabetic patients will require insulin therapy.

[Prevention of bacterial infection using selective intestinal decontamination in patients with cirrhosis admitted to intensive care. Controlled study in 120 patients]. / Prévention de l'infection bactérienne par décontamination intestinale sélective chez des patients cirrhotiques admis en soins intensifs. Etude contrôlée chez 120 malades.

All cirrhotic patients admitted on a medical intensive care unit, were included in a randomized trial of selective intestinal decontamination provided there was no infection on admission. The selective intestinal decontamination consisted of a regimen of 3 oral, nonabsorbable antibiotics for the 74 first patients (Neomycin 1 gr, Colistin 1.500.000 U, Nystatin 1.000.000 U, every 6 hours), then of norfloxacin, 400 mg BID for the following patients. The duration of treatment was at least 5 days. Of the 120 patients, initially randomized to receive or not the treatment, 26 were ultimately excluded, mainly (18 cases) because of infection present but unrecognized at the time of admission. Ninety four patients were thus compared for the efficiency of the treatment, 45 in the treated group and 49 in the not treated group. The results showed a significant reduction of the episodes of septicemia in the treated group (4 versus 12, P = 0.044). This reduction was evident only for septicemia due to gram negative germs. Mortality was unaffected. When the risk factors were studied, bacterial infection was linked to the degree of hepatic failure. We recommend selective intestinal decontamination for cirrhotic patients admitted on intensive care unit, particularly when hepatic function is poor.

[Unexplained fever or inflammatory syndrome. Diagnostic value of liver puncture-biopsy]. / Fièvre ou syndrome inflammatoire inexpliqués. Intérêt diagnostique de la ponction-biopsie hépatique.

The value of transcutaneous biopsy of the liver was assessed in a series of 110 cases of fever of unknown origin or of unexplained inflammatory syndrome. Liver histology was useful to the ultimate etiological diagnosis in 12 cases (11 per cent). The result of a transcutaneous biopsy of the liver was considered an essential aid to the ultimate diagnosis in 7 of these 12 cases. A hepatic lesion regarded as useless for the ultimate diagnosis was present in 16 cases (14.5 per cent). In the other cases, hepatic histology was normal or showed a non-specific reactive hepatitis. Unicteric cholestasis was present in 73 per cent of the cases but was of no predictive value for the detection of a useful hepatic lesion. On the other hand, serum transaminase levels were significantly higher when a useful lesion of the liver was observed.

Klebsiella pneumoniae liver abscess with septic endophthalmitis. The role of computed tomography.

Klebsiella pneumoniae liver abscess associated with septic endophthalmitis is a rare observation. To our knowledge, only 10 cases have been reported in the international literature. We report a further case of complication occurring in an adult woman with hypothyroidism, and comment on the role of CT for the work-up.

Ludwig's angina and mediastinitis due to Streptococcus milleri: usefulness of computed tomography.

Despite intensive use of antibiotics, Ludwig's angina remains a potentially lethal infection because of the risk of upper airway obstruction and spread into the mediastinum. We present two patients who survived mediastinitis complicating Ludwig's angina due to Streptococcus milleri. Computed tomography performed early in the course of the disease detected pus collections and directed appropriate drainage procedures.

Clinical and immunologic features of livedo reticularis in lupus: a case-control study.

PURPOSE: We recently noticed the occurrence of both livedo and elevated anticardiolipin antibody levels in a small number of patients with lupus. The purpose of our study was two-fold: (1) to investigate whether anticardiolipin antibodies were more common in lupus patients with livedo than in those without; and (2) to determine if the features of Sneddon's syndrome (livedo and cerebrovascular disease) also were found in patients with lupus. PATIENTS AND METHODS: In this case-control study of lupus patients without significant renal impairment, 29 patients with livedo reticularis (cases) were compared clinically and immunologically with 29 patients without livedo (controls). RESULTS: Both groups shared many disease characteristics and were similar in age and sex. However, they differed markedly in other respects. Elevated anticardiolipin antibody levels were significantly more common in the cases. Indeed, 81% of all cases from our study sample had elevated anticardiolipin levels. A history of thrombosis and thrombocytopenia--clinical associates of the anticardiolipin antibody--was also significantly more common in cases than in controls. The relative odds of livedo reticularis were 23-fold greater in those with elevated anticardiolipin levels than in those without these antibodies. The estimated proportion of livedo-positive patients with elevated anticardiolipin antibodies in a general lupus population without significant renal impairment was 0.77. CONCLUSION: The association between livedo reticularis and cerebrovascular disease, originally described by Sneddon in otherwise healthy individuals, also applies to lupus patients. The presence of elevated anticardiolipin antibody levels in 10 of 11 such patients suggests that the anticardiolipin antibody may be of pathogenetic importance in the manifestations of Sneddon's syndrome in lupus and also possibly in the idiopathic form of this disease.

Immune mediated mechanism for thrombosis: antiphospholipid antibody binding to platelet membranes.

Because thrombocytopenia occurs frequently in patients with anticardiolipin (aCL) antibodies and thrombosis, some investigators have proposed that aCL antibodies may play a direct part in thrombosis by binding and activating platelets. To test this proposal experiments were performed to determine whether aCL antibodies can bind platelets. Preincubation of aCL positive sera with freeze-thawed platelets caused significant inhibition of aCL activity in four serum samples tested. Antibodies with cardiolipin binding activity were subsequently eluted from these platelets. Total phospholipids extracted from platelets inhibited aCL activity, and the specific phospholipids bound were shown to be phosphatidylethanolamine, phosphatidylserine, and phosphatidylinositol. It is concluded that aCL antibodies can bind phospholipids in platelet membranes but pertubation of the membrane must first occur.

Pregnancy and lupus: prognostic indicators and response to treatment.

A cohort study was undertaken of 18 consecutive pregnancies in 16 patients with systemic lupus erythematosus without significant renal impairment. Of these, eight each had at least two previously unexplained pregnancy failures, 10 had elevated anticardiolipin antibodies, nine had the lupus anticoagulant and five had antibodies to Ro. Twelve live births resulted but a Downs syndrome baby died in the perinatal period. Fetal morbidity was confined to four cases of fetal growth retardation, all in mothers positive for anticardiolipin antibodies, and fetal distress in another two. There were no cases of the neonatal lupus syndrome. There was one maternal death. An obstetric history of at least two previously unexplained pregnancy failures and the presence of maternal anticardiolipin or anti-Ro antibodies accurately predicted fetal loss in six of seven cases. No other serological risk factors for fetal loss were identified. We were unable to show that suppression of antibodies in those mothers with at least two previously unexplained pregnancy failures improved fetal outcome.

The Budd-Chiari syndrome. Possible pathogenetic role of anti-phospholipid antibodies.

The case of a young woman with the Budd-Chiari syndrome is reported. She first noticed abdominal symptoms following a late spontaneous abortion. Antiphospholipid antibodies were detected in her serum. We suggest that these may have been causally related to the development of her hepatic disease.

Lupoid sclerosis: a possible pathogenetic role for antiphospholipid antibodies.

The case of a 45-year-old woman is described who developed transverse myelitis over a one-year period. Serological tests suggested a lupus-like illness. Antibodies to cardiolipin of the IgM class were detected in high titres in her serum. These may have played a part in the pathogenesis of her disease.

Thrombocytopenia in SLE and related autoimmune disorders: association with anticardiolipin antibody.

Anticardiolipin antibody levels were determined in 116 patients with systemic lupus erythematosus and related autoimmune disorders. Forty-three of these patients had a history of thrombocytopenia--36 of whom had SLE, three primary Sjögren's syndrome, two rheumatoid arthritis and two mixed connective tissue disease. IgG anticardiolipin antibody levels were raised in 31 (72%) of the 43 patients and IgM anticardiolipin antibody levels were raised in 19 (44%). There was a strong statistical correlation between thrombocytopenia and raised anticardiolipin antibody levels of both the IgG (P less than 0.001) and IgM (P less than 0.01) immunoglobulin classes. Of the 20 patients with the highest IgG anticardiolipin antibody levels 16 had a history of thrombocytopenia. We suggest that anticardiolipin antibodies may play a direct role in mediating platelet destruction in autoimmune disorders.

Anticardiolipin antibodies in autoimmune thrombocytopenic purpura.

Using a recently devised solid phase radioimmunoassay to detect anticardiolipin antibodies, we report the presence of these antibodies in 30 of 96 patients with chronic autoimmune thrombocytopenic purpura (AITP). IgG anticardiolipin antibody levels were elevated in 14 patients and IgM anticardiolipin antibody levels were elevated in 27 patients. We suggest that these antibodies may mediate peripheral platelet destruction by binding to phospholipids in the platelet membrane. It is also conceivable that the presence of anticardiolipin antibodies may select a subpopulation of patients with chronic AITP who may go on to develop other autoimmune disorders, such as systemic lupus erythematosus.

[Systemic lupus erythematosus. A new look]. / Lupus érythémateux disséminé. Un nouveau regard.

The systemic lupus erythematosus is a chronic inflammatory condition in which many abnormalities of the immune system have been described. Recent work has shown a subset of antiphospholipid antibodies which are apparently independent of the classical antinuclear antibodies. Their association with the false positive VDRL and the lupus "anticoagulant" is statistically significant. Clinically, these antibodies are associated with thrombosis, thrombocytopenia, thrombotic and demyelinating neurological features.