[Hypertrophic osteoarthropathy and aortic graft infection: Two cases]. / Ostéoarthropathie hypertrophiante et infection de prothèse aortique : deux observations.

INTRODUCTION: Hypertrophic osteoarthropathy (HOA) located to lower extremities may be the initial manifestation of an infected aortic graft. CASE REPORTS: We report two patients with HOA secondary to aortobifemoral vascular prosthesis infection and aortoenteric fistula. As reported in the literature, initial manifestations included fever, painful swelling of limbs, joint pain, clubbing and in one case intestinal bleeding. These symptoms preceded frank episodes of septicaemia due to a wide variety of bacteria (microbial enteric flora). Bone scan was an appropriate tool for confirming the diagnosis of HOA. Abdominal computed tomography, and PET-scan were useful for detecting vascular infection. Aortoenteric fistula remained difficult to identify. CONCLUSIONS: Mechanisms involved in the pathogenesis of HOA associated with infected graft are poorly understood, but vascular endothelial growth factor (VEGF) could play a major role. The mortality of infected aortic grafts remains high, but knowledge of this association could lead to early diagnosis and accurate treatment.

[Inappropriate low glycated hemoglobin and hemolysis]. / L'hémolyse : une cause d'erreur dans l'interprétation de l'hémoglobine glycosylée.

Hemoglobin A1c (HbA1c), measured regularly in the patients with diabetes, is the major form of stable glycated hemoglobin and has to be maintained below 6.5% to prevent or decrease the risk of chronic complications. HbA1c reflects mean blood glucose levels of the previous 3 months. We report the case of a particularly low HbA1c in a diabetic patient despite high plasma glucose levels, that was induced by auto-immune hemolysis related to an Evans syndrome. All hemolytic disorders can be responsible for falsely reassuring HbA1c values. Clinicians must be aware that hematologic status has to be considered for the correct interpretation of HbA1c results.

[Extrapontine myelinolysis of favorable outcome in a patient with autoimmune polyglandular syndrome]. / Myélinolyse extrapontine d'évolution favorable au cours d'une polyendocrinopathie auto-immune.

INTRODUCTION: Extrapontine myelinolysis is a well-known complication of hyponatremia and its treatment. It rarely occurs without central pontine myelinolysis, usually after overly rapid correction of hyponatremia. Its prognosis is considered poor. EXEGESIS: We report the case of a patient with autoimmune polyglandular syndrome with subacute adrenal failure responsible of severe hyponatremia. Despite a well-conducted treatment, the patient developed acute anxiety, catatonia, dysphagia and parkinsonism revealing extrapontine myelinolysis demonstrated on MRI. Outcome was favorable. CONCLUSION: Extrapontine myelinolysis may occur in the absence of central pontine myelinolysis despite a treatment of hyponatremia conducted according to published guidelines. Treatment should be extremely cautious when hyponatremia has been lasting for more than 48 hours.

[What do general practitioners expect from internal medicine? Results of postal survey]. / Qu'attendent les médecins généralistes de la médecine interne? Résultats d'une enquête postale sur le secteur de la Loire et des départements limitrophes.

SUBJECT: The place of internal medicine in the French health care system is a matter of debate. In the process of writing down a project for the department of internal medicine of a University hospital, we decided to assess the expectations of general practitioners toward internal medicine in general, and toward this department in particular. METHODS: We carried out a postal survey over a population of general practitioners working in the referral area of our University hospital. The answers of physicians familiar or not with our department were compared with a chi 2 test. RESULTS: 852 questionnaires were sent over and 49.5% were returned. The general practitioners as a whole acknowledge the classical features of internal medicine: medicine dealing with diagnosis and taking in charge unexplained symptoms; holistic medicine in cases of multiple illnesses; medicine dealing with systemic diseases as well as medicine of "niches" (incidentalomas, orphan diseases). The specific orientations of this department of internal medicine are also well known by most physicians: a great majority (94%) of them are satisfied with the help they receive; they stress the need on swift sending of letters (74%); above all, 94% of them wish to obtain rapid appointments for their patients at their request. CONCLUSION: These results are in complete accordance with our aim of setting a general internal medicine department at the disposal of general practitioners. They do confirm that outpatient consultation is the hardcore of internal medicine that must be readily available to the patients referred by their general practitioner.

[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.

Residual inflammatory process after aortoiliac reconstructive surgery.

BACKGROUND: The aim of the present study was to investigate the inflammatory reaction and its evolution in patients who underwent a prosthetic vascular procedure. Moreover the participation of this chronic process, during the follow-up, as a promoting or a consequence of vascular injury must be discussed. METHODS: Thirty-four patients were enrolled in the study. All patients had an aortic disease and underwent a prosthetic vascular procedure. Preoperative exclusion criteria were an emergency situation, diabetes, infection, chronic inflammatory disease, cancer and hemopathy. Postoperative exclusion criteria were the same together with abdominal complications and additional surgery during the follow-up. The inflammatory process was investigated with the measurement of blood acute phase proteins, haptoglobin, alpha1-glycoprotein acid, C-reactive protein and interleukin-6, before, immediately after surgery and several months after surgery. RESULTS: An increase in acute phase proteins was not observed to the same extent for all the studied patients. Before the surgical procedure, chronic inflammatory process was revealed by an increase in haptoglobin (52.9 p 100) and alpha1 glycoprotein acid (52.9 p 100) whereas increase in C-reactive protein (26.4 p 100) and interleukin-6 (92 p 100) are related to an acute process. Later after surgery, the chronic inflammatory process remained but differed from the observed process before surgery only by haptoglobin (61.7 p 100) and interleukin-6 (47 p 100). CONCLUSIONS: The presented results, observed during the follow-up of vascular surgery focused on persistent inflammatory process and the surgical procedure did not modify the time course of this process. The evolutionary disease could be considered as chronic and independent of the local effect.

[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.

[Contribution of 99mTc MAG3 in hypertension in an elderly subject with renal artery thrombosis]. / Apport de la scintigraphie au 99mTc MAG3 dans l'HTA du sujet âgé avec thrombose d'une artère rénale.

To ascertain the responsibility of renal artery thrombosis for the genesis of arterial hypertension, the methods available are not sufficiently sensitive and reproducible, and the residual revascularization maintained by a vicarious arterial network is not easy to demonstrate. Renal scintigraphy with technetium 99m-labelled mercaptoacetyltriglycine (MAG3) was performed in 4 old and severely hypertensive male patients with chronic thrombosis of one renal artery. With this tracer the thrombotic kidney was detected lately and weakly at the vascular and nephrographic stages. When the functions of both kidneys were compared, that of the affected kidney was always estimated at less than 5%. At the excretory stage a residual activity could be detected in the kidney with renal artery thrombosis. Owing to the specific biophysical behaviour of the tracer, MAG3 scintigraphy coupled with arteriography and assays of plasma renin activity in the veins contribute to the decision concerning nephrectomy.

[Pheochromocytoma disclosed by isolated inflammatory syndrome]. / Phéochromocytome révélé par un syndrome inflammatoire isolé.

Among the atypical forms of phaeochromocytoma the isolated inflammatory form is rare and difficult to diagnose clinically. The authors report such a case, where computerized tomography and magnetic resonance imaging contributed enormously to the diagnosis.

[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.

[TeBG and thyrotoxicosis in the hot thyroid nodule]. / TeBG et thyrotoxicose dans le nodule chaud thyroïdien.

The binding capacity of serum TeBG (testosterone-estradiol binding globulin), the plasma concentrations of thyroid hormones and the TSH response to TRF (200 micrograms i.v.) have been measured in female patients with a solitary autonomously functioning thyroid nodule (n = 26) or with a cold thyroid nodule (n = 20). It was found that TeBG was higher than the upper limit for normal (1.77 micrograms/dl) in the patients (n = 10) with increased serum concentrations of thyroid hormones and in 5 patients among 16 with normal thyroid hormone levels. After surgical removal of the nodule, the increased TeBG levels fell down within the normal, while the response of TSH to TRF which was suppressed before surgery, was recovered. In patients with a cold nodule, the administration of dl-Thyroxine (200-300 micrograms/daily) suppressed the response of TSH to TRF and increased slightly TeBG from 0.97 +/- 0.08 to 1.29 +/- 0.10 micrograms/dl (p less than 0.05) with a value higher than 1.77 micrograms/dl in 5. These data suggested that the pituitary secretion of TSH and the liver production of TeBG have a different threshold of sensitivity to thyroid hormones action. It is proposed that the measure of TeBG is a tool for the diagnosis of thyrotoxicosis in patients with autonomous thyroid nodules.