[Urine Dipstick Screening tests: can they allow to conclude the absence of a urinary tract infection in diabetic hospitalised patients]. / Evaluation d'une pratique professionnelle : la bandelette urinaire permet-elle d'exclure le diagnostic d'infection urinaire chez le patient diabétique adulte hospitalisé ?

UNLABELLED: Asymptomatic urinary tract infections are common in diabetic patients. The aim of this 10 months prospective study is to evaluate urinary dipstick tests versus cytobacteriological examination to conclude the absence of urinary tract infection in diabetic subjects. Each diabetic patient hospitalised for less than 8 hours and for whom it was decided a cytobacteriological examination was included in the study (141 samples). At the same time (and at patient's bedside) a dipstick urinalisys (glucose, leucocytes, nitrite, blood, protein, and ketone) was carried out. Sensitivity, specificity, negative predictive value, post test probability and negative likehood ratio were calculated. RESULTS: the combination of leucocyte zone with nitrite zone (both negative) has a 85,2% sensitivity, avoids 65% of cytobacteriology, but has an odd ratio at 0,20. Those results are improved when the glucose zone (negative test or less than 4 crosses) is taken into account, with a 96,3% sensitivity, 63,4% cytobacteriology avoided and a negative likehood ratio at 0,06. CONCLUSION: The addition of the glucose test to the usual leucocytes and nitrite tests seems to allow one to conclude the absence of urinary tract infection in diabetic patients; this is worth studying with a more extensive sample.

[Antineutrophil cytoplasmic antibody associated vasculitis: an uncommon side effect of propylthiouracil]. / Vascularite avec anticorps anticytoplasme des polynucléaires neutrophiles: une complication rare du propylthiouracile.

INTRODUCTION: Agranulocytosis or allergic skin reactions are common side effects of antithyroid drugs. Antineutrophil cytoplasmic antibody (ANCA) associated vasculitis is very uncommon. CASE REPORT: We report a 29-year-old woman treated with propylthiouracil for Graves' disease who developed a vasculitic skin involvement. ANCA with antimyeloperoxidase specificity were documented. Symptoms resolved after discontinuation of the drug. CONCLUSION: ANCA associated vasculitis is an unusual complication of propylthiouracil. Prognosis is conditioned by renal and pulmonary involvement.

[Non-tuberculous systemic granulomatosis mimicking sarcoidosis but related to a specific etiology. Study of 67 cases]. / Granulomatoses systémiques pseudosarcoïdosiques d'étiologie déterminée et non tuberculeuse. Etude de 67 observations.

PURPOSE: Systemic granulomatosis (SG) are frequently encountered in internal medicine. Despite a large list of aetiologies, the investigations remain often negative leading to the diagnosis of atypical sarcoidosis. The spectrum of the causes, as well as evolution of these SG is not clearly delineated in the literature. METHOD: We analyzed the case reports of all but tuberculous GS submitted at the National Meetings of the National French Society of Internal Medicine from 1990 to 2006. RESULTS: Sixty-seven cases were included in the study. The average age at the beginning of the symptoms was 47.8 years and 28.4% of the patients were female. The median diagnostic delay was one year. General symptoms were present in 73.1% of the cases. The involved organs were the liver (46.3%), lungs (25.4%), lymph nodes (22.4%), digestive tract (16.4%), skin (16.4%), spleen (14.9%). The granuloma were detected mainly in the liver (38.8%), lymph nodes (17.9%), bone marrow (16.4%) and lungs (11.9%). Elevated erythrocyte sedimentation rate or increased C reactive protein serum levels were noted in 65.6% of the patients. Before diagnosis, 19.4% of the patients received a corticotherapy. The most common diagnoses were infections (65.6%) followed by drugs (19.5%), "toxic substances" or various foreign bodies (5.9%), neoplasias (5.9%) and immune deficiencies (3%). The evolution was favourable in 80% of the cases but 8.3% of the patients died. The disease course of the patients having received a corticotherapy prior to the diagnosis was more unfavourable with a death rate of 45%. CONCLUSION: In atypical sarcoidosis (fever, advanced age, increased acute phase reactants...) a specific aetiology and especially an infectious disease should be ruled out before considering the diagnosis of sarcoidosis. Corticotherapy is a factor of poor prognosis.

[Cardiovascular risk reduction: impact of an international project]. / Prevenzione cardiovascolare. Riduzione del rischio cardio- vascolare: risultati e prospettive di un progetto.

The Euroaction project, promoted by European Society of Cardiology, aims to determine whether a nurse co-ordinated, multidisciplinary, family based preventive cardiology programme could help more patients and their families achieve the recommended European lifestyle, risk factor and therapeutic goals for cardiovascular disease prevention. EUROACTION was evaluated in a paired cluster randomized controlled trial, and the primary care branch included 6 European countries. Consecutive patients > 50 years and < 80 years, with no history of cardiovascular disease, were prospectively identified by the general practitioners with one of the following: (i) high total cardiovascular risk (HeartScore > or = 5% over 10 years, either now or when projected to age 60 years) and on no medical treatment for blood pressure, lipids or diabetes; (ii) on treatment with anti-hypertensive and/or lipid-lowering drug therapies started in the last year but with no diabetes; (iii) diagnosed with diabetes mellitus (treated by diet alone or with oral hypoglycaemic drug therapy and/or insulin) within the last three years in both intervention and usual care practices. All eligible high risk individuals and their partners were then invited by the nurse for an assessment of their lifestyle, risk factors and therapeutic management as soon as possible after identification. In the primary care intervention branch 1019 patients have been enrolled with no differences by sex and mean age 62, while in the control branch 1005 patients were recruited with mean age 63, female were 43%. The main results show that Intervention group (I) had a statistically significant improvement compared to Usual Care (UC) in the assumption of recommended quantity of fruit and vegetables (78.4% I vs 38.8% UC p=0.005), in the weight loss (weight loss > al 5% in subjects with BMI > 25 kg/m2) (16.5% I vs 6.8% UC p=0.005), in blood pressure control both in people specifically treated with drugs and untreated (respectively 52% I vs 35% UC p=0.04 and 65% Ivs 45% UC p=0.02), in reaching the European target for total cholesterol (Total Cholesterol < 5.0 mmol/l) during the study year (from 21.9% to 35.8% (I) absolute increase 12.7% (p=0.025) vs from 33% to 32.2% (UC)). No significant differences were found about change of smoking habits. The experimented intervention model based on a multidisciplinary approach and nurses leaded showed a good one year impact in reducing cardiovascular risk factors in high risk people. This model should be further tested in local contexts.

[Recurrent unexplained lipothymia: do not forget the capillary leak syndrome]. / Lipothymie récidivante inexpliquée: penser au syndrome d'hyperperméabilité capillaire idiopathique.

INTRODUCTION: Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by recurrent spontaneous episodes of hypovolaemic shock due to marked plasma shifts from the intravascular to the extravascular space. It presents as the characteristic triad of hypotension, haemoconcentration and hypoalbuminemia. CASE REPORT: We describe a patient with SCLS with recurrent lipothymia who presented first with delayed oedema that was thought to be due to orlistat treatment. On the second episode the patient was seen with a pulmonary hypertension when plasma came back into vessels. On the third time the characteristic triad led to the diagnosis of SCLS. DISCUSSION: SCLS should be considered in the differential diagnosis of recurrent hypovolemic shock without identifiable cause. Nevertheless, symptoms may be restricted to sole lipothymia or transient oedema or delayed hypoalbuminemia rendering the diagnosis difficult.

[Nelson's syndrome: course of aggressive pituitary corticotroph adenoma]. / Syndrome de Nelson: évolution d'un adénome hypophysaire corticotrope agressif.

Nelson's syndrome was defined in 1958 as the association of an expanding pituitary tumor with high ACTH secretion after bilateral adrenalectomy for Cushing's disease. Pituitary MRI and ACTH measurements led to the definition of Nelson's syndrome as the proliferation of a corticotrophic microadenoma or an aggressive and highly proliferative tumor residue induced by the decreased glucocorticoid inhibition after bilateral adrenalectomy. Now, the problem is not the definition of Nelson's syndrome but rather the identification of markers predictive of tumor growth. Based on a typical case and a review of the literature, we point out some predictive markers of tumor growth after bilateral adrenalectomy: young age at diagnosis, presence of tumor residue on pituitary MRI before adrenalectomy, markers of tumor aggressiveness (Ki-67>3%, mitoses, nuclear PTTG) and increase of ACTH levels during the first months following adrenalectomy.

[Hemophagocytic syndromes]. / Les syndromes hémophagocytaires.

Hemophagocytic syndromes are the clinicobiological translation of an unconnected macrophagic activity with hemophagocytosis. Their physiopathology is related with a deregulation of the T lymphocytes and an excessive production of cytokines. Acquired hemophagocytic syndromes are mostly associated with underlying pathology which they can reveal: immunodeficiency, infections (mostly of viral origin), hemopathies and cancers, auto-immune diseases. The main clinicobiological features are fever, hepatosplenomegaly and peripheric bicytopeny. In the majority of cases, the diagnosis is confirmed by a myelogram which shows the presence of benign histiocytes, actively phagocyting the hematopoietic cells. The pejorative prognosis of hemophagocytic syndromes (actual mortality rate 30 to 45%) requires an early therapy which associates etiological treatment of the underlying affection with pathogenic treatment (pulse of corticosteroids, immunoglobulins, immunosuppressors, or plasmapheresis).

[Bacterial cerebral aneurysms without infectious endocarditis: analysis of a case and review of the literature]. / Les anévrismes bactériens cérébraux sans endocardite infectieuse: étude d'un cas et revue de la littérature.

INTRODUCTION: Bacterial intracerebral aneurysms, which are a common complication of infectious endocarditis, are unusual without Osler's disease. EXEGESIS: From the case report of a man with a bilateral bacterial intracranial aneurysm without endocarditis resulting in an hypopituitarism, we undertook a literature review of bacterial intracerebral aneurysms without endocarditis. CONCLUSION: Although this review has found few cases, this kind of aneurysms seems to have different features from those secondary to infective endocarditis: younger age of incidence, majority of Staphylococcus aureus, clinical presentation as a thrombophlebitis of the cavernous sinus, location of aneurysm on bigger cerebral artery.

[Gemcitabine-induced thrombotic microangiopathy]. / Microangiopathie thrombotique due à la gemcitabine.

INTRODUCTION: Thrombotic microangiopathy (TMA) regroups the hemolytic and uremic syndrome (HUS) and thrombocytopenic thrombotic purpura (TTP). The TMA associated with cancer can be secondary to cancer, hence similar to TTP, or to chemotherapy, creating an HUS. Gemcitabine, used in the treatment of pulmonary, pancreatic and urothelial carcinomas, is generally well tolerated, but has recently been implied in the occurrence of TMA. OBSERVATION: In a patient treated for a metastatic urothelial carcinoma, HUS developed after 8 cues of gemcitabine used alone. After symptomatic treatment and withdrawal of gemcitabine, the hematological abnormalities disappeared and renal function returned to preceding values. DISCUSSION: The incidence of TMA is of around 5 to 6% of metastatic carcinomas. Gemcitabine-induced TMA are of recent occurrence and some twelve cases have been reported. Their occurrence is delayed with regard to the initiation of gemcitabine. They lead to HUS with good prognosis since, on withdrawal of gemcitabine the renal abnormalities regress. Search for TMA should therefore be proposed after more than 10 cycles of treatment with gemcitabine.

[Spontaneous portal vein thrombosis associated with acute cytomegalovirus infection in an immunocompetent patient]. / Thrombose porte spontanée associée à une infection aiguë à cytomégalovirus chez une patiente immunocompétente.

BACKGROUND: Portal vein thrombosis (PVT) generally results from a local cause (hepatocellular and pancreatic carcinoma). Spontaneous PVT related to a general cause is less common. We report here a case of spontaneous PVT associated with acute cytomegalovirus (CMV) infection in an immunocompetent patient. CASE REPORT: A 31-year-old white female was admitted with fever and lymph node enlargement. The patient was a heavy smoker and was taking oral contraception. Blood tests revealed an inflammatory syndrome. Liver enzymes were elevated (2N) and platelet count was 118 G/l. Abdominal ultrasonography disclosed partial portal thrombosis. Computed tomography did not show any evidence of a hepatic or pancreatic mass. Protein S, protein C, and anti-thrombin III levels were normal. No antiphospholipid antibodies, no mutation for factors II and V and no abnormality suggestive of paroxysmal nocturnal hemoglobinuria at flow cytometry could be demonstrated. Acute CMV infection was diagnosis with positive viremia (PCR). The patient was given anticoagulation treatment and has done well with no relapse. CONCLUSION: Cytomegalovirus, by damaging endothelial cells, is thought to trigger a cascade of events leading to deep vein thrombosis. CMV infection does not appear to act alone on endothelial cells but rather behaves as an associated factor.

[Acute aseptic meningitis in adults. Retrospective study of 32 cases]. / Méningites puriformes aseptiques chez l'adulte. Etude rétrospective de 32 cas.

OBJECTIVE: The objective of this study was to analyze the characteristics of a series of acute aseptic meningitis (AAM) (defined by sterile cerebrospinal fluid (CSF) with more than 10 leucocytes per mm3 and a neutrophilic polynuclear-rich formula). We analysed the initial management, the reasons for antibiotic and/or antiviral treatment, the aetiologies, the need for lumbar puncture and the progression... METHOD: We retrospectively analyzed 32 cases of AAM (out of a total of 130 cases of meningitis) from two departments of internal medicine in Lyon, diagnosed between January 1996 and January 2003. Only the files fulfilling the AAM criteria were retained, selecting those with a minimum neutrophilic polynuclear level of 30% in the CSF. RESULTS: The mean age was 32.6 years (range: 18-75) and predominantly male patients (59%). On admission, 87% of the patients exhibited fever, but only 9% remaining so for 72 hours. Viral syndrome before admission was noted in 59% of cases, with seasonal predilection (summer: 39%, winter: 35%). The motivation for lumbar puncture (LP) was meningeal syndrome (44%), headache (94%) and vomiting (47%). The average rate of neutrophils in the CSF on admission was 63% (range: 30-96). A control LP on Day 3 was performed 16 times (50%): mean PNN rate at 18% (range: 0-80), lymphocyte rate=68% (range: 20-95). Most of the patients (77.4%) had a C reactive protein (CRP) lower than 50 mg/l on admission (range: 5-320). A cerebral scan was performed 10 times (31%) and was abnormal 2 times (multiple cerebral abscesses, possible intracranial hypertension). An antibiotic (84%) and/or antiviral (34%) treatment was initiated. The evolution on Day 3 was favourable (87.5%): no fever, regression of the meningeal syndrome, with a mean duration of hospitalisation of 8.3 days (range: 1-60). Search for Herpes simplex virus and Enterovirus was made with PCR analysis in 20 cases (62.5%): no positivity for the herpes, but 9 for the Enterovirus. The systematic blood cultures were positive only once (staphylococcal infective endocarditis with cerebral abscesses). The diagnosis of bacterial meningitis was evoked 3 times (prior antibiotic treatment). DISCUSSION: The frequency of Enterovirus AAM should encourage this type of investigation in order to withdraw the often initiated anti-infectious treatment rapidly, and hence avoid a second lumbar puncture.

[Parathyroid adenoma as an ectopic carotid mass. Apropos of a case]. / Adénome parathyroídien en position carotidienne ectopique. A propos d'un cas.

Authors report a case of parathyroid adenoma as lateral palpable cervical mass, with serious hypercalcemia. MRI and ultrasound investigations were performed preoperatively. No other pathological parathyroid gland was found. Surgical treatment did not include the exploration of the four parathyroid glands. Long term follow-up is necessary.