Vasculitis restricted to the lower limbs: a clinical and histopathological study

BACKGROUND

Rare cases of vasculitis restricted to the lower limbs have been reported, but the characteristics, outcome and response to treatment of this entity are not well known.

OBJECTIVE

To describe the clinical, complementary examinations and response to treatment of this rare entity in the first retrospective series, and to compare data with historical pooled cases.

METHODS

Retrospective analysis of all biopsy-proven cases observed over a 10-year period in four French tertiary medical units. Diagnosis of vasculitis restricted to the lower limb required the absence of any clinical symptom and complementary test finding, suggesting major extramuscular visceral involvement.

RESULTS

11 patients were included. Vasculitis restricted to the lower limb was associated with disabling muscle pain of the calves. Fever was present in 50% of cases; ankle arthralgia in 50% and skin involvement in 40%. MRI was the cornerstone of the diagnosis, showing hyperintense signal in T2 weight and in T1 weight after gadolinium injection. MRI findings correlated well with clinical outcome and were useful in guiding biopsy. Muscle biopsy was consistent with a polyarteritis nodosa-type vasculitis in only 40% cases, whereas a leucocytoclastic vasculitis was seen for all other cases. Treatment with corticosteroids was effective in all cases, but there were relapses requiring immunosuppressive agents in 54% of cases.

CONCLUSION

Vasculitis of the calf muscles must be considered for patients with calf pain and with a biological inflammatory syndrome.

Endocrine function in 98 HIV-infected patients: a prospective study

Endocrine function was prospectively evaluated in 98 patients (73 men and 25 women) infected by HIV in various stages of illness: Centers for Disease Control groups II (19), III (20), IVA and IVC2 (27), IVC1 and IVD (32). Testing included baseline and post-stimulation evaluation of gonadal, thyroidal, and adrenal axes. Although adrenal function was within normal values in most cases, with no differences between patient groups, nine out of 98 patients had either a low baseline or post-stimulation serum cortisol, cytomegalovirus adrenalitis being suspected in two cases. Mineralocorticoid response was normal in all individuals. The main abnormalities were sick euthyroid syndrome with low tri-idothyronine and/or thyroxine in 16% of patients and hypotestosteronemia in 29% of men with AIDS. These abnormalities, related to a functional deficiency of the hypothalamic-pituitary axis, were highly correlated with the degree of illness, i.e. weight loss and low CD4+ cell count. It was concluded that endocrine dysfunction in HIV-infected patients is rarely of clinical significance, that it is related more to cachexia and advanced disease than to HIV or opportunistic infections, and that it could serve as a prognostic marker.

[Empirical treatment of febrile episodes in granulocytopenic patients with a combination of piperacillin and ofloxacin. Preliminary study]

We evaluated the efficacy and toxicity of piperacillin-ofloxacin as an empiric treatment of fever in patients with neutropenia. 24 febrile episodes occurring in 21 patients (mean neutropenia: 204/mm3) were treated. The neutropenia was due to an hematologic malignancy in 6 cases and to chemotherapy in 15 cases. Fever was related to septicemia in 4 cases, urinary tract infection in 1 case, other infectious sites without microbiological documentation in 11 cases, and was of unknown origin in 8 cases. Empirical therapy was started within 24 hours of the occurrence of fever greater than 38.5 degrees C with the combination of intravenous piperacillin (12 g/day in 3 divided doses) and oral ofloxacin (400 mg/day in 2 doses). The overall response rate was 86% (19/22) of evaluable cases, with an immediate success rate (apyrexia within 48 hours) of 46%. Of the 3 failures, one was bacteriologically documented and was due to a multiply resistant strain of Staphylococcus haemolyticus (to which both piperacillin and ofloxacin were resistant). The therapy was clinically well tolerated in all except 3 patients, in whom intolerance to intravenous piperacillin was observed, leading to discontinuation of the drug in 2 cases. More extensive and comparative trials should better determine the place of this piperacillin-ofloxacin combination as first-line treatment of febrile episodes in patients with neutropenia.

Septicaemia due to Actinobacillus actinomycetemcomitans with endocarditis and spinal epidural abscess

A case of tricuspid valve endocarditis with spinal epidural abscess caused by Actinobacillus actinomycetemcomitans is reported in a 74-year-old male with an endocardial pacemaker. Despite antibiotic treatment, removal of the endocardial wire was necessary for recovery.

[Granulomatous hepatic localizations in Whipple's disease. Apropos of 2 cases]

In two patients "granulomatous hepatitis" was diagnosed upon examination of liver biopsy specimens taken because of prolonged fever with poor general condition. Observed lesions were small nodules without necrosis: follicular adentitis was also found in one patient. Diagnosis of Whipple disease was established by examination of a biopsy specimen of the intestinal mucosa. Study of the hepatic lesions after Gram and PAS staining, done in one patient, did not demonstrate the suggestive intrahistiocytic particles. Confrontation of clinical evidence and histologic findings in lymph node and intestinal biopsy specimens is required for diagnosis.