Porridge-like tuberculous cardiac tamponade: treatment difficulties in the Horn of Africa.

A 16-year-old boy was hospitalized for fever, chest pain, and cardiovascular collapse. Transthoracic echocardiography revealed a 30-mm circumferential echogenic "porridge-like" pericardial effusion with signs of cardiac tamponade. Tuberculosis (TB) was suspected because of its prevalence in Djibouti. Emergency pericardiocentesis was attempted, but only 10 ml of pericardial fluid was obtained. Subxiphoid pericardiotomy and drainage were then performed, and pericardial fibrinous pockets were surgically collapsed. Antituberculosis chemotherapy was given, and the pericardial effusion progressively disappeared without corticosteroids. The diagnosis of TB was subsequently confirmed by cultures of the pericardial fluid. A pericardial biopsy was normal. After 3 months of follow-up, there was no sign of constrictive pericarditis. Pericardiocentesis may fail in cases of advanced-stage fibrinous TB pericardial effusion. Thus, pericardiotomy with complete open draining is the only lifesaving procedure.

Epidemiology of hepatocellular carcinoma in Finistère. Prospective study from June 2002 to May 2003.

OBJECTIVES: The aims of this prospective study were to evaluate the incidence of hepatocellular carcinoma (HCC) in Finistère, an administrative district of western France, and to highlight epidemiological characteristics. METHODS: From June 1st 2002 to May 31st 2003, all cases of HCC in Finistère were registered prospectively. Standardized incidence rates were calculated. RESULTS: One hundred and six cases of HCC were registered. Standardized incidence rates were 13.8/100000 among men and 0.8/100000 among women. Among the incident cases of HCC, 52% were discovered in patients consulting for symptoms, and 28% in patients undergoing screening. The new non-invasive diagnostic criteria of HCC were used in 60% of cases. HCC was associated with cirrhosis in 89 patients (84%). Excessive alcohol intake was the main cause of cirrhosis. In all, 27 patients (25.5%) received potentially curative treatment. CONCLUSION: Incidence of HCC is high in Finistère. The proportion of patients given potentially curative treatment is still low, illustrating how difficult screening can be when alcoholic cirrhosis predominates in the target population.

[Ascites due to constrictive pericarditis]. / Ascite par péricardite constrictive.

INTRODUCTION: We report a case in which ascites revealed chronic constrictive pericarditis (CCP) of tuberculous origin. OBSERVATION: A 65 year-old man had developed ascites the past over few weeks and oedema of the lower limbs. Treatment was surgical and consisted in pericardiectomy. DISCUSSION: Chronic constrictive pericarditis has become rare in industrialised countries with the reduction in the incidence of tuberculosis. Currently, its principle aetiologies identified are previous cardiac surgery and radiotherapy. Treatment is usually surgical and gives excellent results. This clinical case clearly illustrates the interest of systematic biological analysis of ascites, since it may reveal a curable disease.

[Thoracic pain of oesophageal origin. Diagnostic management and treatment]. / Douleurs thoraciques d'origine oesophagienne. Prise en charge diagnostique et thérapeutique.

FROM AN ETIOLOGICAL POINT OF VIEW: Thoracic pain is a frequent symptom. Before confirming the oesophageal origin of the pain, a coronary disease must be excluded. Two principle causes are source of thoracic pain of oesophageal origin: gastro-oesophageal reflux disease and oesophageal motility abnormalities. THE DIAGNOSTIC APPROACH: This must include the questioning of the patient and the usual paraclinical examinations. To confirm the diagnosis, these examinations must establish a chronological relationship between the symptoms and the abnormalities. For economic reasons, following a normal gastroscopy, there is a tendency to propose an empirical proton pump inhibitor (PPI) test rather than a 24 hour pH-metry antireflux as first line. The improvement or even the disappearance of the symptoms confirms the diagnosis; long-term treatment with a double dose of PPI should therefore be envisaged. The pH-metry with search for results should be proposed to the non-responders and to patients with atypical reflux manifestations. Dysphagia and odynophagia suggest an oesophageal motility disorder that basal manometry should confirm. A chronological relationship is rarely revealed, but the sensitivity of the pH-meter can be enhanced by provocation tests. REGARDING TREATMENT: Other than achalasia, treatment of the other spastic-like motor disorders is not well codified. Diltiazem is efficient. Some patients exhibit a hyperalgic oesophagus. The physiopathological mechanisms are still theoretical. Low dose tricyclic antidepressors and psychological management are useful.