Effects of prolonged, purine-free total parenteral and enteral nutrition on urate homeostasis in man.

The influence on human urate homeostasis of prolonged, totally purine-free nutritional support, using total parenteral (TPN) or elemental enteral (EN) nutrition, is not well known. In a prospective study, we measured weekly serum uric acid, renal urate excretion and clearance, together with parameters of hydration, in 58 normally hydrated patients receiving prolonged (15 to 170 days) purine-free TPN (30 patients) or EN (28 patients) for various gastrointestinal disorders. A marked, early and sustained decrease (p less than 0.001) in serum uric acid was observed in TPN (155 +/- 9 mumol/l at day 7 versus 318 +/- 13 mumol/l before nutrition, mean +/- SEM) as well as in EN patients (192 +/- 11 mumol/l at day 7 versus 320 +/- 16 mumol/l before nutrition), together with a significant (p less than 0.01) rise in renal urate clearance. The urate clearance/glomerular filtration rate ratio increased significantly, while there was no significant change in natremia or plasma osmolarity. Serum urate and urate clearance returned to normal within 8 days of refeeding with a normally purine-containing diet. Replacement of TPN by EN or vice versa, or substitution of glucose by fructose resulted in no change in hypouricemia. A 4-day oral supply of purines (125 mg/day) in EN patients was associated with a 53% rise (p less than 0.01) in serum urate. We conclude that prolonged, purine-free TPN and elemental EN are a new cause of marked hypouricemia which is mainly due to increased urate clearance, the mechanism of the latter is still poorly known, but is not related to extracellular volume expansion.

[Massive sarcomatous infiltration of the liver disclosed by jaundice and hepatocellular failure in Waldenström's disease]. / Infiltration sarcomateuse massive du foie révélée par un ictère et une insuffisance hépatocellulaire au cours d'une maladie de Waldenström.

We report herein the case of a patient with Waldenström macroglobulinemia in whom an immunoblastic sarcoma produced acute jaundice and hepatic failure. Transvenous liver biopsy, performed because of coagulation deficiencies, revealed massive infiltration of the liver by the sarcoma. Immunofluorescence study showed numerous portal and sinusoidal cells stained exclusively by anti-micron anti-kappa antisera. As shown by others in the literature, this study supports evidence for the same clonal origin of the two proliferations. Chromosomal abnormalities were found in marrow and blood cells (trisomy 5 and 20, 6 q-, 7 q+, and 8 p-); their role in emergence of sarcoma is discussed. This case shows that immunoblastic sarcoma emerging during the course of Waldenström macroglobulinemia may be revealed by severe hepatic manifestations.

[Acute respiratory distress disclosing leptospirosis]. / Détresse respiratoire aiguë révélant une leptospirose.

The respiratory manifestations of leptospirosis are usually benign. A case is reported of anicteric leptospirosis with serious pulmonary affection. The clinical symptoms, the radiological manifestations and haemodynamic investigation were suggestive of an acute respiratory distress by non-haemodynamic pulmonary oedema. In accordance with other authors, one would be justified in including this acute respiratory failure as part of the acute respiratory distress syndrome of the adult (ARDS).

Peutz-Jeghers syndrome with metastasizing carcinoma arising from a jejunal hamartoma.

The association of Peutz-Jeghers (P-J) syndrome and gastrointestinal carcinoma is well documented, but an unequivocal histologic demonstration that malignancy may originate in a hamartomatous polyp has been very rarely given. A patient with the P-J syndome is described, in whom a definite intestinal adenocarcinoma with metastases to omentum and celiac lymph nodes was shown to originate in a jejunal hamartoma. Evidence that malignancy was derived from hamartomatous structures was given by the following observations: (a) Adenocarcinoma was intimately intricated with smooth muscle bands, and well-defined transitional zone of malignant cells could be observed in several glands of the degenerated P-J polyp; and (b) close to malignant areas, glands of this polyp exhibited a less-differentiated epithelium, but were still intermixed with nonstriated muscle bundles, which strongly suggest dedifferentiation of hamartomatous structures.

Association of cimetidine and bone-marrow suppression in man.

A 29-year old woman who was on steroids for Behcet's disease received intravenous cimetidine for severe gastrointestinal bleeding. A bone-marrow examination performed a few days prior to cimetidine treatment showed a normally active marrow. On the fifth day of cimetidine therapy, agranulocytosis (800/ml) and a very low platelet count (40,000/ml) were observed; bone-marrow failure was documented both by biopsy and aspiration. No other drug known to be myelotoxic was given. This severe hematologic side effect of cimetidine resolved within 10 days after discontinuation of the drug.

[Acute ulcerative colitis associated with cytomegalic inclusion virus in a non-immunodepressed patient (author's transl)]. / Colite ulcéreuse aiguë avec inclusions cytomégaliques chez un sujet non immunodéprimé.

A new case of acute ulcerative colitis associated with cytomegalic inclusion virus within the colonic wall is reported. Some unusual features are discussed, such as the absent defect in cellular or humoral immunity, the location of the lesion which were limited to the sigmoid colon, and the fatal outcome of the disease. The possible pathogenic relationship between cytomegalic infection and acute a chronic ulcerative colitis are reviewed.