Fulminant lupus pneumonitis complicating systemic lupus erythematosus in the elderly

Fulminant lupus pneumonitis is a rare complication of SLE. We report a case of 75 years-old male patient with SLE who developed pneumonia and severe respiratory failure requiring mechanical ventilation. Refractory respiratory distress complicating noninfectious fulminant lupus pneumonitis did not respond to methylprednisolone and intravenous immunoglobulin treatment.

Tuberculous tenosynovitis of the hand: A challenging diagnosis

Tuberculous tenosynovitis of the hand is a very rare condition. Herein, we report the case of tuberculous tenosynovitis of the hand in a 32-year-old woman. We highlight the success of anti tuberculosis drugs alone without resort to surgical treatment.

Early onset of scleromyxedema Arndt‐Gottron associated with a monoclonal gammapathy: Successful treatment with intravenous immunoglobulins

Arndt‐Gottron (S‐AG) syndrome or scleromyxedema is a scarce disease characterized by a generalized papular and sclerodermoid eruption and systemic manifestations that can lead to significant morbid‐mortality. Interesting, S‐AG can be associated with a paraprotein. We report an exceptional scleromyxedema case associated with a benign monoclonal gammapathy in an old woman.

Vascularite à anticorps anti-membrane basale glomérulaire secondaire au Covid-19 : observation inédite !

Introduction

La maladie des anticorps anti-membrane basale glomérulaire (Ac anti-MBG) est une affection auto-immune médiée par des anticorps dirigés conte la MBG et alvéolaire définissant le syndrome pneumo rénal. Plusieurs facteurs environnementaux ont été incriminés dans la genèse de cette maladie notamment les infections virales des voies respiratoires. Nous rapportons le cas d’une maladie à Ac anti-MBG survenue suite à une infection par le Sars Cov2.

Observation

Patiente âgée de 56 ans, non tabagique, suivie pour une insuffisance antéhypophysaire sous traitement substitutif, qui a consulté aux urgences pour fièvre, rhinorrhée, toux, diarrhée avec douleurs abdominales diffuses et oligurie évoluant depuis 02 semaines. L’examen objectivait une fièvre à 39 °C, un état hémodynamique stable, une pression artérielle à 11/06 mmHg et une tachycardie à 110 bpm. La saturation pulsée de l’oxygène était à 95 % à l’air ambiant. Elle présentait des œdèmes des 2 membres inférieurs de type rénal. Les bandelettes urinaires ont objectivé une hématurie à 2 croix associée à une protéinurie à 2 croix. Le reste de l’examen était sans anomalies. La patiente présentait à la biologie une créatinine à 1295 μmol/L, une protéinurie de 24 heures à 1 g, un syndrome inflammatoire et une anémie hypochrome microcytaire. L’échographie rénale a objectivé des reins de taille normale avec une bonne différenciation cortico-médullaire.

Devant les signes respiratoires et la fièvre, une infection par le Sars-Cov2, fortement suspectée vue le contexte pandémique, était confirmée par un test PCR. Par ailleurs, devant l’insuffisance rénale aiguë, la patiente a eu des séances d’hémodialyse et une ponction biopsie rénale avec étude en immunofluorescence montrant une glomérulonéphrite extra-capillaire associée à des dépôts linéaires d’IgG et une nécrose fibrinoïde. Les étiologies toxiques, iatrogènes, infectieuses (hormis la Covid) et néoplasiques étaient éliminées. Devant ce tableau clinico-biologique, histologique et la positivité du bilan immunologique montrant des Ac anti-MBG positif à 3+ des anticorps antimyéloperoxydase positif à 2+ associés à une cryoglobulinémie positive, le diagnostic de maladie des Ac anti-MBG était retenu. Un complément d’exploration par fibroscopie bronchique avec lavage broncho-alvéolaire était en faveur d’une hémorragie intra-alvéolaire avec un score de Golde à 102. La patiente a reçu donc des boli de méthylprednisolone à la dose de 800 mg/j durant 3 jours, relayés par une corticothérapie orale à la dose de 1 mg/kg/j associés aux échanges plasmatiques et à l’hémodialyse. Après guérison de l’infection COVID-19, des cures de cyclophosphamide ont été initiées. L’évolution sur le plan rénal était marquée par le passage au stade terminal de l’insuffisance rénale chronique nécessitant l’épuration extrarénale régulière.

Conclusion

Plusieurs cas de vascularite post infection Covid-19 ont été rapportés dans la littérature. Les mécanismes physiopathologiques responsables de cette association restent jusque-là mal élucidés. Ainsi, devant toute anomalie du sédiment urinaire et/ou de la fonction rénale survenant au cours ou au décours de la maladie Covid-19, une vascularite doit impérativement être évoquée afin d’instaurer un traitement adapté le plutôt possible, seul garant d’un meilleur pronostic.

La pandémie COVID-19 a-t-elle changé mon médecin ? Point de vue du patient de médecine interne

Introduction

Patients et méthodes

Résultats

Conclusion

Acquired Bartter Syndrome in Primary Sjögren Syndrome

Renal tubular involvement in Sjögren's syndrome (SS) often described with renal tubular acidosis, nephrogenic diabetes insipidus, or rarely with Fanconi syndrome. SS presenting with clinical features of Bartter's syndrome or Gitelman's syndrome is rare. We report a case of a female patient who presented an acquired Bartter syndrome with a primary SS.

AB0451 PRIMARY SJOGREN’S SYNDROME IN MEN

Background:

Primary Sjogren’s syndrome (PSS) is characterized as an autoimmune exocrinopathy, but this disorder also may involve extraglandular organs, giving rise to multisystem disease. Although the first case reported by Dr Mikulicz was a 42 year old man [1], there are only few reports describing the clinical picture of Sjogren’s Syndrome in males

Objectives:

To determine whether there were any clinical and biological differences between male and female tunisian patients with primary Sjogren’s syndrome (PSS).

Methods:

We studied 60 patients with pSS according to American-European Consensus Group (AECG), attending an Internal Medicine departement in Tunisia. The nine (15%) male patients in this cohort comprised the male group described in this study

Results:

The average age of men at diagnosis was 53.2 years [31 to 73 years]. Male SSp was revealed by sicca symptoms (55.5%), by extra glandular manifestations (33.3%). Fourty-four percent of our male patients had a positive result for a minor salivary gland biopsy (grade III or IV).

Extraglandular manifestations during the course of the disease were present in 6 cases (66%) of our male patients with pSS. weight loss and raynaud’s phenomenon were more common in men. a significantly greater percentage of men had neurological involvement (66.6%vs 23,7) and and pulmonary involvement, notably a restrictive syndrome (66.6% vs 31,1%, p=0.043). The positivity of Anti-nuclear antibodies, anti-SSb and rheumatoid factor were significantly less common in males.

Anemia was significanty more common in the male patients (p=0,049). No cases of Lymphoma in the male patients in our series.

Eighty-eight percent of the men were treated with corticosteroids. In our series, the use of immunosuppressants was not necessary in male patients.

Conclusion:

Although pSS is typically a disease affecting women, clinicians should be aware that it may be diagnosed in male patients. Although men were at the same risk for the development of extraglandular complications, there were significant serologic and immunogenetic differences. In Sharp contrast to women with Sjogren’s syndrome, men with Sjogren’s syndrome were more seronegative in our series.

References:

[1]Mikulicz J. Discussion at Verein fur wissenschaftliche Heilkunde zu königsberg. Berl Klin Wocchenschr 1888; 25:759.

[2]Gondran G, Fauchais A, Lambert M, Ly K, Launay D, Queyrel V, et al. Primary Sjogren’s syndrome in men. Scandinavian journal of rheumatology. 2008;37(4):300-5.

[3]Virdee S, Greenan-Barrett J, Ciurtin C. A systematic review of primary Sjogren’s syndrome in male and paediatric populations. 2017;36(10):2225-36

Disclosure of Interests:

None declared

Prolonged fever and intra-cardiac thrombosis revealing Behçet's disease

BACKGROUND

Prolonged fever (PF) is a challenging problem for physicians since it can be the first manifestation of a large variety of pathologies. Exceptionally, intra-cardiac thrombus (ICT) could explain PF and reveal Behçet's disease (BD). We are reporting a 45-year-old man with BD who has these unusual manifestations.

CASE REPORT

A 45-year-old man presented with PF and inflammatory biological syndrome during a few months. Echocardiography showed an inhomogeneous and mobile mass in the left auricle. During his hospitalization, the patient had multiple oral aphtosis. The angioscanner showed a sacciform aneurysm of the coeliac trunk. The diagnosis of BD was retained and he was treated with high doses of steroids and cyclophosphamide with a favorable follow-up.

CONCLUSION

The search for BD should be systematic in view of any suggestive manifestation of severe cardiovascular complications like ICT especially in a young adult man from a high endemicity region.

Seizures, Metabolic Acidosis and Coma Resulting from Acute Isoniazid Intoxication

Isoniazid is an anti-tuberculosis drug, used commonly for treatment and prophylaxis of tuberculosis. Acute isoniazid intoxication is characterized by a clinical triad consisting of metabolic acidosis resistant to treatment with sodium bicarbonate, seizures which may be fatal and refractory to standard anticonvulsant therapy, and coma. Treatment requires admission to the intensive care unit for ventilatory support, management of seizures and metabolic acidosis. Pyridoxine, in a dose equivalent to the amount of isoniazid ingested, is the only effective antidote. We report the successful treatment of two isoniazid intoxication cases: the case of a child developing an accidental acute isoniazid intoxication and an adult case of isoniazid intoxication with the intent of suicide.

Successful resolution of Hemophagocytic lymphohistiocytosis associated to brucellosis in the adult

Hemophagocyticlymphohistocytosis (HLH) is a proliferation of histiocytes with importanthemophagocytosisoccurring in different organs such as the spleen and the bone marrow. HLH is now increasingly diagnosed in the context of infections, malignancies and connective tissue diseases. Although brucellosis is an endemic infection in Tunisia, its association with HLH is a very rare condition which should be considered in patients with splenomegaly and cytopenia. Here, we describe brucellosis associated HLH in a 31 year-old man. The patient was admitted to our hospital with fever, sweating, and fatigue. Physical and laboratory findings revealed splenomegaly, pancytopenia, elevated serum transaminases, triglycerides, lactate dehydrogenase, and ferritin, and bone marrow hemophagocytosis. The Brucella agglutination test was positive. The patient improved after treatment with Rifampin and doxycyclin.

Headache in a young woman: do not forget Susac’s syndrome

Susac syndrome is a rare disease characterized by the clinical triad of encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss. This underdiagnosed condition needs to be considered in the differential diagnosis of a broad variety of disorders. An early diagnosis is important as treatment can halt disease progression and prevent permanent disability. Herein, we report a case of Susac syndrome in a 31-year-old woman and we highlight how challenging an early diagnosis was and the importance of an aggressive therapeutic approach, including the combination of steroids and other cytotoxic drugs.