Risk assessment for foot ulcers among Tunisian subjects with diabetes: a cross sectional outpatient study.

BACKGROUND: Diabetic foot is an underestimated and redoubtable diabetes complication. The aims of our study were to assess diabetic foot ulcer risk factors according to International Working Group on the Diabetic Foot (IWGDF) classification, stratify patients into risk categories and identify factors associated with higher-risk grade. METHODS: Cross-sectional setting over a period of 07 months, patients were randomly selected from the diabetic outpatients attending our unit of diabetology. Questionnaire and clinical examination were made by the same physician. Patients free of active foot ulcer were included. RESULTS: Among 230 patients evaluated, 10 had an active foot ulcer and were excluded. Five patients (2.27%) had a history of foot ulcer and 3(1.36%) had a lower-limb amputation. Sensory neuropathy, as measured by the 5.07(10 g) Semmes-Weinstein monofilament testing, was present in 23.63% of patients, whereas 36.82% had a peripheral arterial disease based on clinical findings, and 43.63% had foot deformities. According to the IWGDF classification, Group 0: 72.72%, Group 1: 5.9%, Group 2: 17.73% and Group 3: 3.63%. After univariate analysis, patients in higher-risk groups were significantly more often female, had higher age and BMI, longer diabetes duration, elevated waist circumference, low school level, retinopathy and hyperkeratosis. Multivariate logistic regression analysis identified 3 significant independent factors associated with high-risk groups: retinopathy (OR = 2.529, CI95 [1.131-5.655], p = 0.024), hyperkeratosis (OR = 2.658, CI95 [1.222-5.783], p = 0.014) and school level (OR = 0.489, CI95 [0.253-9.44], p = 0.033). CONCLUSIONS: Risk factors for foot ulceration were rather common in outpatients with diabetes. The screening of patients at risk for foot ulceration should start early, integrated with sustainable patient education.

[Difficult diagnosis of Erdheim Chester disease revealed by central diabetes insipidus]. / Le cas clinique du mois : Diagnostic difficile d'une maladie d'Erdheim Chester révélée par un diabète insipide central.

The Erdheim Chester disease is a rare form of non Langerhans cell histiocytosis. Its rarity and its unspecific clinical presentation, make that its diagnosis is often delayed. We report the case of a 50 years old female who has an Erdheim Chester disease, revealed by a central diabetes insipidus with thickening of the pituitary stalk, with associated gonadotropin deficiency. The Erdheim Chester disease was suspected because of the association with other evocative systemic lesions: eyelid xanthelasmas and bone lesions in metaphyseal-diaphyseal region of the upper and lower ends of both femurs and tibias on bone scan. Confirmation of the diagnosis was initially difficult and delayed, with initially inconclusive cutaneous and bone biopsies. It is the histological re-reading with immunohistochemical study of the bone biopsies which allowed the diagnosis by showing histiocytes positive for the CD68 and negative for the CD1a and the protein S100. The diagnosis was made with a delay of 3 years. In conclusion, although rare, Erdheim Chester disease should be suspected in front of a set of clinical and radiological arguments. Diagnostic confirmation is based on histological and especially immunohistochemical studies.

La maladie d'Erdheim Chester est une forme rare d'histiocytose non langerhansienne. Par sa rareté et son tableau clinique peu spécifique, son diagnostic est souvent retardé. Nous rapportons le cas d'une patiente âgée de 50 ans ayant une maladie d'Erdheim Chester révélée par un diabète insipide central avec épaississement de la tige pituitaire à l'IRM cérébrale et insuffisance gonadotrope associée. Cette maladie a été suspectée devant l'association d'autres atteintes systémiques évocatrices : des lésions cutanées à type de xanthélasmas sus-palpébraux de couleur jaune-orange et une atteinte osseuse au niveau métaphyso-diaphysaire des extrémités supérieures et inférieures des deux fémurs et tibias objectivée à la scintigraphie osseuse. La confirmation du diagnostic était initialement difficile et retardée, avec des biopsies cutanée et osseuse initialement non concluantes. C'est la relecture histologique avec étude immuno-histochimique des biopsies osseuses qui ont permis le diagnostic en montrant des histiocytes positifs pour le CD68 et négatifs pour le CD1a et la protéine S100. Le diagnostic positif a été posé avec un retard de 3 ans par rapport à la première consultation. En conclusion, bien que rare, la maladie d'Erdheim Chester devrait être suspectée devant un faisceau d'arguments cliniques et radiologiques. La confirmation diagnostique repose sur l'étude histologique et, surtout, immuno-histochimique.

[Iron deficiency anemia in people aged 65 years and older: a cohort study of 102 patients]. / Anémies ferriprives chez les personnes âgées de 65 ans et plus: Etude d'une cohorte de 102 patients.

PURPOSE: Iron deficiency anemia is a common hematological abnormality in the older people. The aim of this study is to determine the clinical and biological characteristics and causes of the iron deficiency anemia in elderly patients. PATIENTS AND METHODS: We performed a retrospective study of 102 patients aged 65 years and older who were hospitalized for iron deficiency anemia in the internal Medicine Department of Mahdia University Hospital, over a 8-year period (January 2005 to December 2012). RESULT: A total of 184 patients aged 65 years or older were hospitalized for anemia during the study period. Iron deficiency was diagnosed in 102 (55.4%) of the patients, 58 were men (56.9%) and 44 were women (43.1%). The mean age was 74.7 +/- 6.3 years. The mean hemoglobin level was 7 +/- 1.7 g/dl. At least one cause of anemia was diagnosed in 90.2% of cases. A gastrointestinal bleeding was the most common etiology (70.5%). Non-steroidal anti-inflammatory drugs and anticoagulants intake were reported in 19.6% of cases. Multiple causes of gastrointestinal bleeding were identified in 12.7% of patients. Chronic gastrointestinal ulcers were the most frequent etiology (25.5%). The frequency of gastrointestinal cancers was 11.7%. CONCLUSION: Iron deficiency was the first cause of anemia in the elderly in our study. Occult bleeding from gastrointestinal lesions was the commonest cause and iron deficiency anemia in the elderly caused by an unknown etiology was rare.

[Benzylthiouracil-induced antineutrophil cytoplasmic antibody-associated cutaneous vasculitis: a case report and literature review]. / Vascularite cutanée à anticorps anti-cytoplasme des polynucléaires neutrophiles induite par le benzylthio-uracile : à propos d'un cas et revue de la littérature.

INTRODUCTION: Vasculitis associated to antineutrophil cytoplasmic antibodies is a rare complication of therapy with antithyroid medication. They were mainly reported in patients treated with propylthiouracil and rarely with benzylthiouracil. CASE REPORT: We report a 22-year-old woman treated with benzylthiouracil for Graves' disease, who developed a vasculitic skin involvement. The presence of antineutrophil cytoplasmic antibodies with anti-myeloperoxidase specificity was documented. The discontinuation of benzylthiouracil was followed by a complete disappearance of skin lesions and of antineutrophil cytoplasmic antibodies. CONCLUSION: To our knowledge, only ten cases of antineutrophil cytoplasmic antibodies vasculitis induced by benzylthiouracil have been previously reported in the literature. Our patient was characterized by the occurrence of isolated cutaneous vasculitis, without renal involvement. Early discontinuation of benzylthiouracil may have prevented the occurrence of severe visceral complication.

Tiroiditis de Hashimoto e hipotiroidismo severo, asociado con un solo nódulo caliente / Hashimoto's thyroiditis and severe hypothyroidism, associated with a single hot nodule

Se presenta el caso de un hombre de 27 años de edad con síntomas de hipotiroidismo severo en evolución desde la adolescencia, y un nódulo tiroideo de 11 mm en el lóbulo derecho. En la ecografía del tiroides, el nódulo era sólido, heterogéneo y con un tejido notablemente atrófico hipoecoico alrededor. La gammagrafía tiroidea reveló un aumento en la captación en el nódulo tanto del 99mTc-pertecnetato como del 131I, con persistencia de la captación de 131I en la imagen de 24 h. No se observó fijación del radiotrazador en el resto de la glándula. Los análisis mostraron unos niveles séricos de TSH > 100 mUI/l, tiroxina libre 0,9 pmol/l (11,5-21,8), anticuerpos antitiroperoxidasa positivo > 1.000 UI/ml y anticuerpos antitiroglobulina negativos. Un año después del tratamiento con levotiroxina, el nódulo redujo en un 40% su tamaño original. La tiroiditis de Hashimoto puede presentarse como un solo nódulo caliente e hipotiroidismo severo. Datos reportados sugieren que el nódulo caliente corresponde a una hiperplasia localizada de las porciones menos dañadas del tiroides. La estimulación crónica por TSH puede haber favorecido el crecimiento nodular y la captación de los isótopos(AU)

We report the case of a 27 year-old man with symptoms of severe hypothyroidism that have evolved since his adolescence. He was found to have an 11 mm right lobe thyroid nodule. On thyroid ultrasound, the nodule was solid, heterogeneous with markedly atrophic hypoechoic surrounding tissue. Thyroid scintigraphy revealed increased 99mTc pertechnetate and 131I uptake, with persistence of 131I hyperfixation after 24 h. There was no fixation of the radiotracer in the remaining tissue. Thyroid function tests found TSH > 100 mIU/l, free thyroxine level 0.9 pmol/l (normal values 11.5-21.8), anti-thyroid peroxydase antibodies strongly positive > 1,000 IU/ml, and anti-thyroglobulin antibodies negative. One year after levothyroxine therapy, the nodule decreased to 40% of its original size. Hashimoto's thyroiditis may present as a single hot nodule and severe hypothyroidism. Data of reported cases suggest that the hot nodule corresponds to a localized hyperplasia of the less diseased portions of the thyroid. Chronic stimulation by TSH may have promoted nodular growth and isotopes uptake(AU)

[Unusual alveolar proteinosis]. / Protéinose alvéolaire atypique.

Pulmonary alveolar proteinosis (PAP), a rare infiltrative disease of unknown aetiology, is characterized by an accumulation of abnormal lung surfactant in the alveoli. The diagnosis is based on the results of the bronchoalveolar lavage (BAL) and sometimes on the lung biopsy. The authors report the case of a 49-year-old woman who was hospitalized for chronic expectoration of the membranes. The chest X-ray revealed alveolar opacities in the lowest part of the right lung. The chest CT scan detected alveolar ground glass opacities with interlobular thickening involving the middle lobe. The BAL was opaque with periodic acid-Schiff stain-positive acellular material. The anatomopathology analysis of the membranes concludes as to the presence of granular eosinophilic material and the absence of neoplasic cells or hydatidous membranes. The diagnosis of PAP was established. Since functional deterioration was not detected, therapy was based on physiotherapy alone. The evolution was favourable, with the disappearance of the symptomatology and the normalisation of the chest X-ray. This observation shows an unusual presentation of PAP based on membrane expectoration and unusual localized lesions.

Hashimoto's thyroiditis and severe hypothyroidism, associated with a single hot nodule.

We report the case of a 27 year-old man with symptoms of severe hypothyroidism that have evolved since his adolescence. He was found to have an 11 mm right lobe thyroid nodule. On thyroid ultrasound, the nodule was solid, heterogeneous with markedly atrophic hypoechoic surrounding tissue. Thyroid scintigraphy revealed increased (99m)Tc pertechnetate and (131)I uptake, with persistence of (131)I hyperfixation after 24 h. There was no fixation of the radiotracer in the remaining tissue. Thyroid function tests found TSH > 100 mIU/l, free thyroxine level 0.9 pmol/l (normal values 11.5-21.8), anti-thyroid peroxydase antibodies strongly positive > 1,000 IU/ml, and anti-thyroglobulin antibodies negative. One year after levothyroxine therapy, the nodule decreased to 40% of its original size. Hashimoto's thyroiditis may present as a single hot nodule and severe hypothyroidism. Data of reported cases suggest that the hot nodule corresponds to a localized hyperplasia of the less diseased portions of the thyroid. Chronic stimulation by TSH may have promoted nodular growth and isotopes uptake.

[Familial idiopathic pulmonary fibrosis associated with autoimmune polyendocrinopathy and epidermodysplasia verruciformis]. / Fibrose pulmonaire idiopathique familiale associée à une polyendocrinopathie auto-immune et à une épidermodysplasie verruciforme.

Familial idiopathic pulmonary fibrosis (IPF) is a very rare and progressively fatal disease. Its pathogenesis is not fully understood and involves damage to alveolar epithelial cells of possibly immunological, microbiological or chemical origin, leading to fibrosing healing. A genetic predisposition has been demonstrated. The authors report the case of a female patient whose brother died at the age of 29 from IPF. She had epidermodysplasia verruciformis since childhood, with the absence of pubertal development. At the age of 31, she presented diffuse interstitial pneumonia. A lung biopsy confirmed the diagnosis of IPF. Endocrine explorations detected hypogonadotropic hypogonadism, primary hypothyroidism and magnetic resonance imaging revealed an empty sella turcica. The association of familial IPF, autoimmune polyendocrinopathy and genetic dermatosis caused by a cellular immune deficiency supports the hypothesis of an immune dysfunction in the pathogenesis of IPF.

[Werner's syndrome and endocrine disorders]. / Syndrome de Werner et atteintes endocriniennes.

Werner's syndrome is a rare autosomal recessive disease caused by the mutation of DNA helicase gene (WRN), characterized by the premature onset of multiple age-related disorders and skin changes similar to those observed in scleroderma. Some endocrinologic and metabolic disorders have been described in patients with Werner's syndrome. We report one case in a 41-year-old man issuing from consanguineous parents, who presented for exploration of hypoglycemic episodes and sexual impotence. Werner's syndrome was diagnosed on the basis of his characteristic clinical appearance. Metabolic disorders were insulin-requiring diabetes and hypertriglyceridemia. Endocrinologic investigation revealed nodular goiter, sub clinical primary hypothyroidism, hypergonadotrophic hypogonadism,adrenal cortical hypofunction and GH deficiency. Pathology examination of the skin biopsy showed a scleroderma-like aspect. Finally, osteoporosis, atherosclerosis and sub-capsular cataract were associated. Thus, in Werner's syndrome metabolic and endocrinologic investigation is necessary in order to treat these disorders and improve the patient's prognosis and life.

[Post-partum autoimmune thyroiditis in a patient presenting with Sheehan's syndrome]. / Thyroïdite auto-immune du post-partum chez une patiente présentant un syndrome de Sheehan.

A 30-year-old women developed post-partum thyroiditis associated with post- partum pituitary infarction. Pituitary stimulation tests demonstrated global pituitary deficiency but there was no thyrotropin response to TRH stimulation and free T4 was normal. Associated goiter and high circulating levels of microsomal antibodies led to the diagnosis of post-partum thyroiditis associated with pituitary deficiency. Two cases of this unusual association have been reported. The underlying pathogenesis might involve post-partum immunological rebound and/or hypocorticism-induced immunological disorders.