[Giant cell arteritis: Role of color-duplex ultrasound]. / Artérite gigantocellulaire : apport de l'écho-doppler.

Giant cell arteritis is the most common primary vasculitis of large-vessel occurring in subjects over 50 years of age. Many imaging techniques has been evaluated to improve the diagnosis of giant cell arteritis. Among these imaging techniques, ultrasound has shown good performances to detect inflammatory involvement of the temporal arteries as well as branches of the aorta. Several publications and recent EULAR recommendations have emhasized the place of this tool in the diagnosis of giant cell arteritis.

[MYH9 syndrome and auto-immune haemolytic anaemia: an unrelated association?]. / Syndrome MYH9 et anémie hémolytique auto-immune : une association fortuite?

INTRODUCTION: The MYH9 syndrome is a group of rare autosomal dominant platelet disorders associating in most of the cases a macrothrombocytopenia and characteristic leukocyte inclusions. Clinical features may include renal, visual, or hearing impairment. The bleeding tendency is usually moderate. CASE REPORT: We report a 28-year-old-man, with an auto-immune haemolytic anaemia associated with a MYH9 syndrome. CONCLUSION: To our knowledge, this is the first report of such an association.

[Upper limb deep venous thrombosis]. / Les thromboses veineuses profondes des membres supérieurs.

Deep venous thrombosis of the upper limb has become recently more common because of the increasing use of central venous catheters. Diagnosis is sometimes difficult. Main causes are pacemaker and central venous catheter related thrombosis. The thoracic outlet syndrome is a rare cause and requires a multidisciplinary diagnostic and therapeutic approach. A systematic research of a thrombophilic disorder is not recommended because of the weak therapeutic impact. Duration of anticoagulation is similar to lower limb deep venous thrombosis despite a lower rate of recurrence. Therapeutic alternatives recently developed include thrombolysis, angioplasty and vein stenting. To date, no randomized controlled studies have evaluated the efficacy and safety of the various treatments that have been proposed for upper limb deep venous thrombosis.

Internal jugular vein thrombosis: outcome and risk factors.

INTRODUCTION: The aims of this study were to analyse the characteristics of patients with internal jugular venous thrombosis. We compared the characteristics of patients with internal jugular venous thrombosis with those of patients exhibiting upper extremity deep venous thrombosis (UEDVT) without internal jugular vein involvement. PATIENTS: From 1998 to 2007, 1948 consecutive patients were referred to our Department of Internal Medicine for deep venous thrombosis. RESULTS: Sixty-four patients exhibited UEDVT. Internal jugular venous thrombosis was diagnosed in 29 patients. Twenty-three patients had secondary thrombosis mainly due to cancer, central venous catheter and ovarian hyperstimulation syndrome; three of the four patients with bilateral DVT exhibited cancer. Six patients had primary internal jugular vein thrombosis. Complications of internal jugular vein thrombosis were pulmonary embolism (10.3%) and post-thrombotic syndrome (41.4%). Under multivariate analysis, significant factors for internal jugular vein thrombosis were older patients (P = 0.0008), female gender (P = 0.0035) and ovarian hyperstimulation syndrome (P = 0.0093). CONCLUSION: Our study underscores that the most common causes of internal jugular vein thrombosis are cancer, central venous catheter and ovarian hyperstimulation syndrome; it also underlines that bilateral internal jugular vein thrombosis is a significant risk indicator of malignancy Thrombosis led to high morbidity related to pulmonary embolism and post-thrombotic syndrome, principally in patients with secondary DVT. The knowledge of predictive factors of internal jugular vein thrombosis seems to be of utmost importance to improve patients' management.

[A double-faced myocarditis: Whipple's disease or sarcoidosis?]. / Une myocardite à deux visages : maladie de Whipple ou sarcoïdose?

INTRODUCTION: Whipple's disease is a systemic infection that may mimic sarcoidosis in its initial presentation. The heart involvement is not uncommon and consists generally in an endocarditis. Myocarditis is less common and is usually accompanied by impairment of heart conduction. CASE REPORT: We report a 56-year-old man with Whipple's disease associated with a myocarditis, initially diagnosed as having a sarcoidosis with cardiac injury. The contribution of the histology and molecular biology on intestinal sampling made it possible to rectify the diagnosis. CONCLUSION: The diagnosis of Whipple's disease should be considered in the presence of a systemic granulomatosis with or without heart involvement. Early diagnosis is important because of effectiveness of antibiotic therapy.

[Anticoagulation clinics for outpatients: a 5-year experience]. / Expérience d'un centre de suivi et de conseil des traitements anticoagulants oraux en médecine de ville: résultats à cinq ans.

INTRODUCTION: Anticoagulation clinics and computerized management of chronic oral anticoagulation increase the time spent in the therapeutic range with both mortality and morbidity reduction. Usually, anticoagulation clinics are hospital-based medical care centers. We report the five-year results from a general medicine center (CSCTA) using a computer-assisted management. METHODS: A prospective cohort observational study of 530 primary care patients that were receiving long term oral anticoagulation. RESULTS: Cardiac arrhythmia (55%), heart valve disease and venous thrombo-embolic disease (30%) represented the most common indications of oral anticoagulation. Patients received fluindione, warfarin and acenocoumarol in 80%, 13% and 7%, respectively. The duration of treatment was at least one year in 54% of the cases, and was at least three years in 25% of the cases. The rate of patients that were in average within the therapeutic range (INR 2-3) was 72%, while 12% were under and 16% over the therapeutic range. Corresponding rates were 82, 17 and 1% respectively for all anticoagulation targets (INR 1.5-4.5). Twenty-six bleeding events (4.9 per 100 patient-years) and four thrombotic complications (0.75 per 100 patient-years) occurred. Life-threatening hemorrhage occurred in 1.3 per 100 patient-years. After the equilibration of the anticoagulation, the average delay of control between two consecutive INR was 19 days. CONCLUSION: The results obtained with CSCTA were similar to those reported by other anticoagulation clinics regarding hemorrhagic complications and time spent in the therapeutic range. In contrast, thrombotic events were less frequent. Because of the absence of a control group, a medico-economic analysis could not be performed.

[Helicobacter pylori prevalence in Raynaud's disease]. / Prévalence des infections à Helicobacter pylori au cours de la maladie de Raynaud.

PURPOSE: Recent studies have suggested that the prevalence of Helicobacter pylori may be more frequent in patients with primary Raynaud's phenomenon (PRP) compared to healthy subjects. These data prompted us to conduct this prospective study, in order to assess the prevalence of H. pylori infection in a large series of patients with PRP. METHODS: Forty consecutive patients with a definite diagnosis of PRP were included in the study. The findings in the PRP patients were compared with those of 80 age- and sex-matched healthy subjects. H. pylori infection was diagnosed using serology and urease breath test. RESULTS: The prevalence of H. pylori infection was as high as 12.5% in PRP patients using both serology and urease breath test, whereas it was found to be 16.7% and 18%, respectively, in healthy controls. CONCLUSION: As prevalence of H. pylori infection was similar in PRP patients compared to controls (P=0.53 and 0.43, respectively), our data underscore that H. pylori infection may not play a role in the genesis of PRP-related vascular complication onset. Interestingly, PRP patients exhibited more commonly digestive symptoms consistent with H. pylori infection compared to controls (P<0.05).

[Infectious or inflammatory aortitis? One case report]. / Aortite infectieuse ou inflammatoire ? A propos d'un cas.

INTRODUCTION: The infectious or inflammatory nature of an aortitis is difficult to assert because the microbiological results are often negative. The development of an aneurysm under treatment is rare, but requires a change in the therapeutic strategy and the etiologic diagnosis needs to be discussed again. EXEGESIS: We report the case of a 69-year-old woman treated by corticotherapy for an aortitis thought to be inflammatory, who required emergency surgery when a dissected aneurysm appeared. The peroperative samples were positive to Streptococcus pneumoniae using polymerase chain reaction and allowed a change of the diagnosis. The patient evolved favorably under antibiotic therapy. CONCLUSION: The decision to treat an aortitis by corticotherapy must be made with caution even if the microbiological tests are negative.

[Aortic involvement in giant cell arteritis. A prospective follow-up of 11 patients using computed tomography]. / Aortite inflammatoire et maladie de Horton. A propos du suivi évolutif scanographique prospectif d'une série de 11 patients.

PURPOSE: To determine clinical and radiological features, using computed tomography (CT-scan) in patients with aortic involvement related to giant cell arteritis (GCA), and to assess both clinical and CT-scan outcome after therapy institution. METHODS: Aortic involvement due to GCA was investigated in all patients, using CT-scan at diagnosis, and at 3, 6 and 12 months follow-up after therapy institution. RESULTS: The 11 consecutive patients consisted of 4 men and 7 women with mean age of 64.5 years. Patients exhibited: constitutional symptoms (N=9; 82%), dorsalgia (N=3; 27%), clinical signs of GCA (N=3; 27%) and of upper limb large vessel impairment (N=6; 55%). CT-scan showed aortitis involving both thoracic and abdominal aorta (N=6; 55%), abdominal (N=2; 18%) or thoracic aorta (N=2; 18%) and thoracic aortic aneurysm (N=1; 9%). At one-year follow-up, CT-scan revealed: complete resolution (N=7; 64%) and improvement (N=3; 27%) of aortic damage; the patient, who had thoracic aortic aneurysm, underwent surgical treatment, as aortic lesion remained unchanged on CT-scan. CONCLUSION: Our study underlines that CT-scan is a helpful test in diagnosis and follow-up of aortic involvement in patients with GCA.

[Association of sarcoidosis and Takayasu's arteritis: an additional case report]. / Association sarcoïdose et maladie de Takayasu: une nouvelle observation.

INTRODUCTION: Takayasu arteritis has been described in association with various auto-immune disorders (mainly inflammatory digestive tract diseases). However, only few cases of Takayasu arteritis associated with sarcoidosis have been reported, raising the question of an association by chance. EXEGESIS: We report the case of a 26-year old woman with a 1-year history of sarcoidosis, who presented with a right painful upper limb, revealing inflammatory humeral, axillary and subclavian arteritis related to Takayasu arteritis. The patient was successfully treated with steroids. CONCLUSION: Our case report suggests that both Takayasu arteritis and sarcoidosis may be related, and that Takayasu arteritis or Takayasu arteritis-like granulomatous vasculitis may be, in fact, a complication of sarcoidosis. It also indicates that a complete vascular clinical examination should be performed in patients with sarcoidosis, in order to detect asymptomatic underlying inflammatory arteritis.

[Tuberculosis peritonitis: an always present disease. About 4 new cases]. / La tuberculose péritonéale: une entité toujours présente. A propos de quatre observations.

INTRODUCTION: Tuberculous peritonitis, a major problem in developing country, occurs preferentially in immigrant population and in patients with acquired immune deficiency syndrome (AIDS). Although rare in France, it did not disappear and epidemiological, clinical and therapeutic approach deserve to be reminded. EXEGESIS: We reported 4 patients (immigrants in two cases), occurred in caucasian and African persons (one with AIDS). Disease was characterized by fever, abdominal pain, anorexia, weight loss and ascites. Biological and radiological were unconclusive. Cell count analysis from ascitic fluid show a lymphocytic predominance with negative direct smear for Ziehl-Neelsen strain. Tuberculous peritonitis was established with combined visual and histological diagnosic laparoscopic examination. CONCLUSION: These observations have the interest to underline that tuberculous peritonitis must be evoked in case of lymphocytic ascitis. We believe an aggressive diagnostic approach, particulary with peritoneal biopsy, is warranted for the diagnosis of tuberculous peritonitis. Validity of PCR amplification is ascitic fluid still needs to be established.

Incidence and prognosis of cancer associated with bilateral venous thrombosis: a prospective study of 103 patients.

BACKGROUND: A strong association between bilateral deep vein thrombosis (DVT) and cancer had been found in one retrospective study. To confirm this finding, consecutive patients with an objective diagnosis of bilateral DVT were followed over 12 months. PATIENTS AND METHODS: One-hundred and three patients, hospitalized for bilateral DVT, were included in the study. Twenty-six patients (25.2%) were already known to have a cancer, 26 (25.2%) had a previous history of venous thromboembolic disease, 44 (42.7%) had a symptomatic pulmonary embolism. The patients were scheduled to be prospectively followed up at 3, 6 and 12 months as outpatients. Information on recurrence, evidence of a new overt cancer and the cause of death were recorded for all patients. RESULTS: A new cancer was diagnosed in 20 (26%) of the 77 patients without known cancer at admission. The risk of cancer was significantly more important in idiopathic thrombosis than in patients with secondary thrombosis (40.5% vs. 12.5%; odds ratio 4.8, 95% confidence interval 1.4, 18.8). Seventy percent of the cancers discovered had already spread. Age, gender, presence of pulmonary embolism, recurrence and location of the thrombosis were not statistically associated with the risk of cancer. The 1-year survival rates of patients with a previously known cancer and patients with a newly discovered cancer were, respectively, 26% and 35% (P = 0.33). CONCLUSIONS: Bilateral DVT is a significant risk indicator of malignancy. Cancer is present in 45% of patients with bilateral DVT and is associated with a poor prognosis.

Tolerance of Iloprost and results of treatment of chronic severe lower limb ischaemia in diabetic patients. A retrospective study of 64 consecutive cases.

BACKGROUND: The aim of this study was to assess the tolerance and report obtained results with a stable prostacyclin analogue (iloprost) in diabetic patients with severe forms of permanent lower limb ischaemia. METHODS: Sixty-four consecutive unselected patients, in stage III and IV of Leriche and Fontaine, turned down for vascular surgery after angiography and treated with iloprost during 28 days, were enrolled in this study. Patients were followed-up clinically (ischemic pain, trophic change, walking distance) and with transcutaneous oxymetry (D28). Long-term assessment (6 and 12 months) was expressed as rate of death, major amputation and of live patients with viable limbs and walking. There was no manifestation of intolerance to iloprost. Were considered as responders patients offering a lack or significant decrease in pain, a reduction of trophic lesions and improvement or recovery of walking. RESULTS: Response at two months is lasting: 29 responders (45.3%) and 35 non-responders (54.7%). At 6 months and one year, we observed that 8 (12.5%) and 15 (24.1%) patients respectively had died; 19 (29.6%) and 22 (34.3%) patients underwent major amputation, but 41 (64%) and 34 (53.1%) patients were still alive with their limb and conservative walking. In responder group, at 6 months, 28 (96.5%) patients were alive without amputation for only 13 (37.1%) among non-responders. At one year, 79.3% of the responders and 31.4% of the non-responders were alive without amputation. A total loss of walking, a segmental amputation and a previous amputation of opposite limb were more often noted in no responder group. But no predictive factor was referred to TcPO(2) in particular. Results ware similar in the group of 136 non diabetic patients treated during the same period (67.9% alive with limb at 6 months). CONCLUSIONS: This retrospective study, despite its limitations, underlines the clinical particularities of critical ischaemia in diabetics and the good tolerance to iloprost. This point allowed patients, in non-surgical chronic critical ischaemia, to avoid being confined to bed and to access to benefits of a early physiotherapy, in association with local treatment. However, no predictive criterion of long-term results could be established, except initial clinical severity and clinical change one month after treatment.